THE  NURSING 

AND  CARE  OF  THE 

NERVOUS ANDJ^E INSANE 


MILLS 


lAtUrma  Stbrarg 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/nursingcareofneOOmill 


NURSING  AND  CARE 
OF  THE  NERVOUS 
AND  THE  INSANE 


BY 

CHARLES  K.  MILLS,  M.D. 

PROFESSOR   OP   NEUROLOGY  IN  THE   TJNIVERSITT   OF  PENNSYLVANIA 
NEUROLOGIST  TO  THE  PHILADELPHIA  GENERAL  HOSPITAL 


TEIRD  EDITION 

REVISED  BY  THE  AUTHOR,  ASSISTED  BY 

N.  S.  YAWGER,  M.D. 

INSTRUCTOR  IN  NEUROLOGY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA 
ASSISTANT  NEUROLOGIST  TO   THE   PHILADELPHIA   GENERAL  HOSPITAL 


PHILADELPHIA  AND  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


COPYKIGHT,  1887,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYBIGHT,  1904,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYEIGHT,    I9IS,   BY   J.   B.   LIPPINCOTT   COMPANY 


FEINTED   BY  J.    B.   LIPPINCOTT   COMPANY 

AT  THE  WASHINGTON  SQUARE  PRESS 

PHILADELPHIA,   tJ.  S.  A. 


PEEFAOE  TO  THIRD  EDITION. 


In  the  present  edition  of  this  work  the  author,  with 
the  assistance  of  Dr.  Yawger,  has  endeavored  to  bring 
it  more  nearly  up  to  date.  Such  a  book  cannot  be 
regarded  as  giving  all  the  information  necessary  to  be 
known  by  nurses  concerning  patients  suffering  from 
nervous  and  mental  maladies.  Useful  anatomical  and 
physiological  data  are  to  be  found  in  the  volumes  upon 
anatomy  prepared  for  nurses  and  in  more  general 
treatises.  The  book  is  chiefly  intended  to  recall  facts 
regarding  nursing  obtained  by  experience.  Attention 
has  been  particularly  directed  to  some  new  facts  regard- 
ing epilepsy,  fibrositis  and  insanity.  New  illustrations 
of  the  charts  and  the  apparatus  most  useful  in  electrical 
practice  have  been  added.  The  unusually  fine  motor- 
point  plates  from  Dr.  Toby  Cohn's  excellent  work  on 
"Electro-diagnosis  and  Electro-therapeutics"  have 
been  obtained  through  the  courtesy  of  the  author  and 
his  publishers.  Instruction  regarding  hydrotherapy, 
not  included  in  previous  editions,  has  been  incorpo- 
rated. The  author  trusts  that  the  book  in  its  revised 
form  will  be  found  more  useful  than  previous  editions. 

Philadelphia,  July  24,  1914. 


PEEFAOE. 


The  contents  of  this  little  book  are  the  substance 
of  a  course  of  lectures  delivered  first  at  the  Training 
School  for  Nurses  of  the  Philadelphia  Hospital,  and 
subsequently  at  the  Woman's  Hospital  Training  School 
for  Nurses,  of  Philadelphia.  While  books  upon  nursing 
are  numerous,  and  a  few  valuable,  no  work  devoted 
especially  to  the  nervous  and  the  insane  had,  so  far  as 
I  know,  appeared  prior  to  the  delivery  of  these  lec- 
tures. Within  the  last  few  years,  however,  several 
books  upon  the  care  of  the  insane  have  appeared  in 
England  and  in  this  country  j  but  none  on  the  nursing 
of  patients  suffering  from  either  functional  or  organic 
nervous  diseases,  not  forms  of  insanity.  I  have,  there- 
fore, felt  that  this  little  book  might  fill  a  want  and 
serve  a  purpose.  In  no  class  of  cases  is  it  more  impor- 
tant for  a  nurse,  care-taker,  or  companion  to  have  good 
principles  of  action  and  clear  notions  of  practice,  than 
among  patients  suffering  from  nervous  or  mental  affec- 
tions. Many  of  these  unfortunates  require  prolonged 
and  elaborate  treatment,  much  of  which  necessarily 
must  be  carried  out  in  the  absence  of  the  physician. 
I  have  frequently  been  asked  by  nurses  where  they 
could  obtain,  in  compact  form,  some  information  as  to 
the  care  of  such  patients,  and  also  as  to  the  use  of 

3 


4  PREFACE. 

massage,  electricity,  bathing,  etc.,  by  nurses.  Many 
books  upon  electricity  and  massage  have  been  published, 
but  these  are  either  too  voluminous,  containing  too  much 
scientific  or  theoretical  matter,  or  they  are  not  adapted 
to  the  comprehension  and  purposes  of  nurses.  They 
are  nearly  all,  especially  the  works  upon  electricity, 
books  for  physicians.  Some  books  upon  nursing  con- 
tain suggestions  or  directions  as  to  apoplexy,  drunken- 
ness, hysteria,  epileptic  seizures,  etc. ;  but  it  will  be 
found,  on  comparing  these  works  with  the  present  vol- 
ume, that  considerable  additions  have  been  made. 


OONTEITTS. 


CHAPTER  I. 

PAOB 

Qualities  and  Qualifications  of  a  Good  Nurse  for  Nervous 
Patients — Social  Service — General  Management  of  Hys- 
teria— Hysterical  Seizures — Epileptic  Seizures — General 
Management  of  Epileptics — Diet  for  Epileptics — Forms 
of  Insensibility — Cases  of  Chronic  Organic  Nervous 
Disease — Sleeplessness — Delirium — Diet  — The  Alcohol, 
Opium,  or  other  Narcotic  Habit 9 


CHAPTER  II. 
Massage — Movements 46 


CHAPTER  III. 

Hydrotherapy — Sponging — Hot  and  Cold  Packs — Salt  Rub — 
Continuous  Bath 65 


CHAPTER  IV. 

Eorms  of  Electricity — Faradic  Apparatus — The  Mechanism, 
Management,  and  Care  of  Faradic  Apparatus — Hints, 
Cautions,  and  Contraindications  in  Using  Electricity — 
Electrodes — Conducting  Cords — Methods  of  Applying 
Electricity — Motor  Points 70 

CHAPTER  V. 
The  Nursing  and  Care  of  the  Insane 96 


LIST  or  ILLUSTRATIONS. 


FIG.  PAGE 

1.  Continuous  Bath 69 

2.  Faradic  Battery 73 

3.  Dubois-Reymond  Coil  with  Galvanic  Apparatus  ...  74 

4.  Faradic  Apparatus  for  Office  Table 77 

5.  Box  of  Electrodes  , 85 

6.  Method  of  Holding  Electrodes  in  one  Hand  ....  87 

7.  Motor  Points  of  Arm,  Anterior  Surface 90 

8.  Motor  Points  of   Arm,  Posterior  Surface 90 

9.  Motor  Points  of  Thigh,  Anterior  Surface 90 

10.  Motor  Points  of  Thigh,  Posterior  Surface 90 

11.  Motor  Points  of  Leg,  Anterior  Surface 90 

12.  Motor  Points  of  Leg,  Posterior  Surface 90 


THE  NURSING  AND  CARE 

OP 

THE  NERVOUS  AND  THE  INSANE. 


CHAPTER    I. 

Qualities  and  Qualifications  of  a  Good  Nurse  for  Nervous 
Patients — Social  Service — General  Management  of  Hys- 
teria— Hysterical  Seizures — Epileptic  Seizures — General  Man- 
agement of  Epileptics — Diet  for  Epileptics — Eorms  of 
Insensibility — Cases  of  Chronic  Organic  Nervous  Disease- 
Sleeplessness — Delirium — Diet — The  Alcohol,  Opium,  or  other 
Narcotic  Habit. 

The  nursing  and  care  of  the  nervous  and  the  insane 
call  for  special  training  in  a  high  degree ;  and  yet  it  is 
difficult  to  systematize  and  formally  set  forth  instruc- 
tions and  regulations  for  such  nursing.  In  fever,  sur- 
gical, obstetrical,  and  other  forms  of  nursing,  much  of 
the  training  has  reference  to  instruments,  dressings, 
temperature  records,  etc.,  to  things  which  can  be  seen, 
handled,  and  illustrated.  In  the  training  of  those  des- 
tined to  care  for  the  nervous  and  the  insane,  a  certain 
amount  of  instruction  as  to  machinery  and  manual  pro- 
cedures must  be  given ;  but  much  of  the  teaching,  from 

the  very  nature  of  the  cases,  must  have  reference  to  the 

9 


10  THE  NURSING  AND   CARE  OF 

conduct,  habits,  and  characteristics  both  of  nurses  and 
patients. 

In  order,  in  the  four  chapters  of  the  present  book, 
to  cover  in  a  practical  way  my  entire  subject,  I  will  not 
be  able  to  give  much  time  to  theoretical  considerations, 
and  I  believe  that  it  is  best  that  this  course  should  be 
followed.  While  it  is  an  advantage,  and  sometimes  an 
important  one,  for  non-medical  attendants  upon  the  sick 
to  have  some  acquaintanceship  with  anatomy  and  phys- 
iology, or  other  branches  of  medical  science,  the  amount 
of  knowledge  of  this  description  absolutely  requisite  is 
limited. 

The  first  chapter  will  be  devoted  to  a  consideration  of 
some  of  the  personal  qualities  and  qualifications  of 
nurses  for  nervous  cases,  and  to  certain  miscellaneous 
matters  in  connection  with  nervous  nursing;  in  the 
second,  massage,  movement,  bathing,  and  certain  in- 
struments will  be  treated  of;  the  third  will  discuss 
electricity ;  and  the  fourth  will  be  on  the  nursing  and 
care  of  the  insane. 

Diseases  of  the  nervous  system  cover  an  enormous 
field  and  experience  has  taught  me  that  while  nurses 
who  are  called  upon  to  care  for  the  nervous  and 
the  insane  may  be  needed  to  aid  the  doctor  in  almost  any 
one  of  the  long  list  of  nervous  and  mental  disorders,  a 
rough  attempt  at  arranging  the  different  classes  of  cases 
in  which  they  are  most  likely  to  be  employed  can  be 
made,  based  upon  the  special  qualifications  which  will  be 
required,  and  the  particular  duties  that  will  be  imposed. 
First  come  the  cases  of  functional  nervous  disorders,  so 


THE  NERVOUS  AND  THE  INSANE.  11 

calkd,  under  which  head  are  included  cases  which  fur- 
nish' an  important  field  for  nurses  thoroughly  trained 
for  their  work, — patients  suffering  from  hysteria  in  its 
manifold  shapes;  the  neurasthenic  or  nervously  ex- 
hausted ;  neurotic  people  in  general,  some  of  them  on 
the  border-land  between  sanity  and  insanity  ;  the  sleep- 
less, the  neuralgic,  and  the  choreic.  In  the  second  place, 
we  find  patients  suffering  from  some  forms  of  insensi- 
bility and  from  certain  acute  organic  affections, — cases 
of  apoplexy,  of  uraemia,  of  sunstroke,  of  cerebro-spinal 
fever,  of  acute  meningitis,  tetanus,  etc.  Thirdly,  there 
are  certain  cases  of  chronic,  organic  nervous  disease, 
some  curable  and  some  incurable, — patients  afflicted 
with  meningitis  cerebral  or  spinal,  the  victims  of  tumor 
of  the  brain  or  spinal  cord,  the  hemiplegic,  the  para- 
plegic, or  sclerotic,  and  the  sufferers  from  atrophic  or 
wasting  diseases.  Under  a  fourth  head  are  included  all 
cases  of  insanity. 

At  the  outset  let  me  speak  briefly  of  some  of  the 
qualities  and  qualifications  of  a  nurse  for  nervous  pa- 
tients. My  first  remarks  will  apply  more  particularly 
to  those  who  will  have  under  their  care  the  sufferers 
from  hysteria,  neurasthenia,  and  other  functional  ner- 
vous disorders.  The  care  of  these  patients  is  in  some 
respects  one  of  the  highest  forms  of  nursing.  They 
sometimes  undergo  a  method  of  treatment  which 
involves,  among  other  things,  more  or  less  complete 
seclusion  from  all  but  physicians  and  attendants ;  and, 
confined  to  their  rooms  for  weeks  or  months,  almost 
isolated  from  the  rest  of  the  world,  their  care  demands 


12  THE  NURSING  AND   CARE   OF 

high  qualities  and  qualifications  in  the  companion  and 
care-taker. 

Let  me  here  quote  the  words  of  one*  whose  wide  ex- 
perience entitles  him  before  all  others  to  speak  as  to 
the  trials  and  qualifications  of  those  to  whom  fall  the 
care  of  the  nervously  sick  : 

"  A  life  spent  beside  such  a  sick-bed  is  indeed  a  test 
alike  of  character  and  health.  It  requires  a  strong 
body  and  a  fortunate  balance  of  moral  and  intellectual 
qualities  to  escape  from  being  made  morbid  by  constant 
contact  with  such  suffering ;  and  intensely  sympathetic 
people  are  surely  hurt  by  it,  and  themselves  grow  mor- 
bidly sensitive.  Where  the  unhappy  invalid  becomes 
exquisitely  ill-tempered  under  the  long  pangs  of  illness, 
the  constant  nurse  must  endure  a  thousand  petty  trials 
of  temper,  and  must  know  when  to  yield  and  when  to 
resist  the  tiny  and  numberless  oppressions  of  her  sick 
tyrant;  but  incessant  battle  with  one's  self  is  exhaust- 
ing, and  soon  begins  to  show  its  results  upon  the  health- 
iest nurse,  cooped  up  in  the  sick-room.  A  pallid  face, 
loss  of  energy,  a  certain  passive  obedience  to  routine 
duties  are  the  sure  consequences." 

While  the  fundamental  qualifications  for  a  good  nurse 
for  nervous  patients  are  those  for  a  good  nurse  of  any 
description,  it  is  important  that  she  should  have  a  few 
special  qualities,  and  should  be  free  from  a  few  particular 
faults  and  foibles.  It  is  in  the  highest  degree  impor- 
tant that  she  should  possess  the  quality  called  tact,  so 

1  "Nurse  and  Patient,"  by  S.  Weir  Mitchell,  M.D.,  LL.D. 


THE  NERVOUS  AND  THE  INSANE.  13 

often  wanting  in  all  walks  of  life.  "  Tact,"  says  Dr. 
Aiiderson/  "  is  a  quality  not  easily  defined ;  but  if  we 
go  back  to  the  original  meaning  we  can  construe  a  de- 
finition upon  it.  It  means,  literally,  touch, — ^the  touch 
of  skill  and  experience.  But  it  has  a  wider  signifi- 
cance; it  includes  the  mental  touch,  something  more 
complete  than  the  other;  not  a  touch  merely,  but  a  grasp, 
— the  grasp  of  the  situation,  the  comprehension  of  a 
difficulty,  the  grasping  of  it  on  all  sides  so  that  it  dis- 
appears in  your  hands." 

A  domineering  nurse  will  not  succeed,  while  a  decided 
one  will  have  the  best  chance  of  success.  Firmness 
should  be  combined  with  gentleness  and  fairness,  and  a 
genuine  good  temper  is  invaluable.  Habits  of  close  ob- 
servation should  be  particularly  cultivated.  The  nurse 
should  carefully  note  differences  in  the  condition  of  the 
patient  when  the  doctor  is  present  and  when  he  is  absent ; 
and  any  tendency  to  deceive  or  simulate  symptoms  should 
be  quietly  reported.  She  should  be  especially  careful 
not  to  talk  too  much  to  the  doctor  about  the  patient 
before  the  latter.  It  is  often  best  for  her  to  retire  from 
the  room  when  the  doctor  is  present,  in  order  to  give  him 
an  opportunity  to  talk  to  the  patient  in  private.  A 
good  nurse  will  soon  learn  to  discriminate  as  to  when 
she  should  go  and  when  she  should  stay,  and  when  and 
how  she  should  make  her  report. 

It  often  falls  upon  the  nurse  to  carry  out  plans  and 


1*' Lectures  on  Medical  Nursing,"  by  J.  Wallace  Anderson, 
M.D. 


14  THE  NURSING  AND   CARE  OF 

invent  expedients  for  amusing  and  occupying  the  pa- 
tients. She  should,  therefore,  have  intelligence  and 
education  to  be  able  to  interest  her  patient  by  either 
conversation,  reading,  or  other  measures.  She  may  fail 
in  this  respect  by  attempting  to  do  too  much,  or  by 
having  an  erroneous  notion  of  her  own  powers.  A 
good  reader  may  interest  patients  of  a  certain  class ;  a 
bad  one  may  torture  them.  Judgment  in  carrying  out 
directions  as  to  amusement  and  occupation  will  call  for 
exercise  of  high  qualities.  If  reading  is  permitted,  the 
right  books  should  be  chosen ;  if  cards  are  resorted  to, 
they  should  not  be  made  a  source  of  excitement  instead 
of  relief;  whatever  the  occupation  or  amusement,  it 
should  be  such  as  is  adapted  to  both  the  physical  and 
mental  conditions  of  the  patients.  In  many  cases  the 
nurse  can  persuade  the  patient  into  usefully  occupying 
moments  which  would  otherwise  be  passed  in  intro- 
spection. 

"  The  nurse  for  these  cases,"  says  Mitchell,*  "  ought 
to  be  a  young,  active,  quick-witted  woman,  capable  of 
firmly  but  gently  controlling  her  patient.  She  ought 
to  be  intelligent,  able  to  interest  her  patient,  to  read 
aloud,  and  to  write  letters.  ...  It  is  always  to  be 
borne  in  mind  that  most  of  these  patients  are  over- 
refined,  sensitive  women,  for  whom  the  clumsiness  or 
want  of  neatness  or  bad  manners  or  immodesty  of  a 
nurse  may  be  a  sore  and  steadily-increasing  trial.  To 
be  more  or  less  isolated  for  two  months,  in  a  room  with 


* "  Fat  and  Blood :  An  Essay  on  the  Treatment  of  Certain  Forma 
of  ^Neurasthenia  and  Hysteria,"  by  S.  Weir  Mitchell,  M.D.,  LL.D. 


THE  NERVOUS  AND    THE  INSANE.  15 

one  attendant,  however  good,  is  hard  enough  for  any 
one  to  endure ;  and  certain  quite  small  faults  or  defects 
in  a  nurse  may  make  her  a  serious  impediment  to  the 
treatment,  because  no  mere  technical  training  will  dis- 
pense in  the  nurse,  any  more  than  in  the  physician,  with 
those  finer  natural  qualifications  which  make  tlieir 
training  available." 

"What  is  required,''  says  Playfair,*  in  a  similar 
strain,  "  is  a  woman  of  kindly  disposition  and  pleasant 
manners,  and  of  sufficient  intelligence  and  education 
not  only  to  fully  appreciate  and  second  the  object  of 
the  medical  attendant,  and  to  report  to  him  the  peculi- 
arities of  each  individual  case,  but  also  to  form  an 
agreeable  companion  to  the  patient  during  her  long 
seclusion/' 

A  good  nurse  will  always  be  loyal  to  the  doctor ; 
and  indeed,  to  be  loyal  to  him  is  always  the  best  service 
to  the  patient.  "Loyalty  to  the  doctor,"  says  Miss 
Weeks,^  very  forcibly,  "  includes  encouragement  of  the 
patient's  faith  in  him,  so  long  as  he  is  in  charge  of  the 
case.  The  imagination  is  so  largely  active  in  disease 
that  to  infuse  a  doubt  and  distrust  into  the  patient's 
mind  is  often  to  destroy  all  hope  of  doing  him  good. 
The  nurse  is  a  connecting  link  between  doctor  and 
patient,  responsible  to  the  one,  and  for  the  other,  and 
can  do  much  to  promote  good  feeling  between  them." 
These  words  apply  with  particular  force  to  nervous 
patients. 

*  "  The  Systematic  Treatment  of  Nerve  Prostration  and  Hys- 
teria," by  W.  S.  Playfair,  M.D.,  F.R.C.P. 
»  "  A  Text-Book  of  Nursing."    Compiled  by  Clara  L.  Weeks. 


16  THE  NURSING  AND   CARE  OF 

Having  detailed  some  of  the  qualities  and  qualifi- 
cations of  a  good  nurse,  let  me  picture  some  of  the 
types  of  faulty  nurses, — at  least  so  far  as  the  care 
of  nervous  patients  is  concerned ;  some  of  them  faulty 
for  any  form  of  nursing.  There  is  the  nurse  who 
talks  too  much.  For  some  nervous  patients,  par- 
ticularly for  those  who  are  just  commencing  a  long 
course  of  treatment  by  rest  and  seclusion,  too  much 
talking  on  the  part  of  the  nurse  is  a  serious  drawback. 
With  the  constitutionally  talkative  nurse  it  is  worse 
than  useless  to  attempt  to  correct  the  habit.  She  will 
talk  in  season  and  out  of  season,  and  is  usually  unable 
to  curb  this  propensity  even  in  the  presence  of  the 
physician  ;  indeed,  she  sometimes  seems  to  exhibit  it  as 
one  of  her  greatest  acquirements.  On  the  other  hand, 
I  occasionally  meet  with  a  nurse  who  does  not  talk 
enough ;  or  who  never  says  anything  when  she  does 
open  her  mouth  ;  that  is,  an  individual  constitutionally 
wanting  in  conversational  powers.  Either  of  these 
extremes  is  bad.  It  is  well  that  a  nurse  for  nervous 
patients  should  talk  sensibly,  intelligently,  and  with 
judgment. 

An  abomination  of  abominations  is  the  habit  which 
some  nurses  have  of  informing  the  doctor  as  to  the  ex- 
act nature  of  the  patient's  disease ;  telling  him  that  the 
case  is  one  of  hysteria ;  whispering  an  opinion  as  to  its 
treatment  in  a  mysterious  manner  ;  or  boasting  of  some 
wonderful  discovery  with  reference  to  the  patient. 

The  too  familiar  nurse  is  also  an  abomination. 
Thr  "iwn  closely  in  contact  for  weeks,  and  it  may  be  for 
months,  it  is  natural  that  a  patient  isolated  from  family 


THE  NERVOUS  AND    THE  INSANE  yj 

and  friends  should  become  attached  to  the  nurse  who  is 
kind  and  sympathetic,  and  at  the  same  time  firm  and 
just.  Even  some  affection  may  at  times  grow  between 
the  patient  and  the  nurse ;  but  it  is  the  duty  of  the  nurse, 
while  neither  morose  nor  distant,  to  preserve  a  quiet 
dignity  and  reserve  of  demeanor.  The  typical,  natural, 
heaven-sent  nurse  will  know  just  what  to  do  in  mat- 
ters of  this  kind,  but  a  few  hints  may  be  of  value  to 
some,  who,  although  possessing  many  virtues,  are  not 
celestially  endowed. 

While  it  is  of  the  utmost  importance  that  all  nurses 
should  pay  proper  attention  to  personal  appearance,  the 
nurse  who  is  vain  and  devotes  too  much  of  her  time  to 
self-adornment  is  especially  obnoxious  to  nervous  pa- 
tients. She  should  not  spend  more  time  in  preparing 
herself  for  exhibition  than  she  does  in  attending  to  the 
interests  of  her  patient. 

The  conceited  nurse  is  a  sore  burden,  but  the  nurse 
who  is  too  humble  is  almost  as  bad.  The  nurse  has 
her  rights  and  a  certain  position  to  sustain.  It  is  for 
her,  like  the  soldier,  to  serve  willingly  and  well,  but  not 
meanly  and  with  mock  humility. 

The  nurse  who  comes  from  a  "  good  family^'  is  some- 
times  a  very  good  nurse,  but  may  nevertheless  be  a  sore 
trial  to  patient  and  physician.  On  the  whole,  it  is  not 
a  bad  thing  to  have  had  respectable  ancestors ;  it  is  not 
to  be  placed  to  one's  discredit  if  one's  progenitors  have 
been  men  and  women  of  distinction ;  but  it  is  better 
that  this  fact  should  appear  in  good  breeding  and  bear- 
ing rather  than  that  it  should  be  reiterated  into  the  ears 
of  all  comers. 

2 


18  THE  NURSING  AND   CARE   OF 

The  Durse  who  assures  you  that  she  is  nursing  sim- 
ply because  she  loves  the  business  is  particularly  un- 
fitted for  the  care  of  nervous  patients.  Such  an  asser- 
tion generally  means  that  the  one  making  it  either  only 
half  believes  in,  or  is  half  ashamed  of,  her  vocation. 
While  nursing  should  not  be  regarded  from  a  mer- 
cenary point  of  view,  while  those  engaged  in  it  should 
love  it  for  its  own  sake  as  well  as  for  what  it  brings, 
it  is  a  business,  and,  at  least,  the  effort  should  not  be 
made  to  impress  the  outside  world  that  an  individual 
who  is  receiving  twenty  dollars  or  more  a  week  is  actu- 
ated wholly  by  philanthropic  motives.  Such  an  effort 
will  usually  fail,  particularly  with  those  who  settle  the 
bills. 

The  nurse  who  quarrels  with  the  servants  is  often  a 
nuisance ;  although  I  must  say  on  her  behalf,  that  in 
my  experience  the  latter  are  most  frequently  the  ag- 
gressors. In  the  rest  treatment,  and  in  some  other  lines 
of  nursing,  the  nurse  is  required  to  look  after  some 
special  matters  of  diet,  sometimes  at  unseasonable  times, 
or  to  otherwise  disturb  the  normal  equilibrium  of  house- 
keeping. Servants  naturally  dislike  those  who,  while 
not  in  the  same  position  as  the  family,  are  on  a  plane 
Higher  than  themselves.  A  nurse  with  tact  and  com- 
mon sense  who  starts  right  in  a  family — except  in 
special  instances  where  an  angel  from  heaven  could  not 
get  along  with  the  cook  or  chambermaid — will  usually 
be  able  to  at  least  so  steer  her  course  as  not  to  come  in 
actual  violent  collision  with  the  servants ;  but  she  who 
attempts  to  put  on  airs  or  to  lord  it  over  the  denizens 
of  the  kitchen  will  usually  be  badly  routed  in  the  end. 


THE  NERVOUS  AND    THE  INSANE,  19 

-Before  taking  up  special  matters  of  nursing,  let  me 
say  finally  that  I  have  noticed  occasionally  too  great  a 
disinclination  on  the  part  of  the  nurse  who  has  been 
accustomed  to  a  certain  line  of  cases,  to  step  out  of  that 
which  she  considers  her  particular  sphere  to  take  hold 
jf  patients  of  any  other  type.  I  regard  it  as  a  high 
quality  in  a  nurse  to  be  willing  to  turn  to  any  form  of 
nursing  in  her  general  line  in  an  emergency.  Nurses 
are  not  to  blame  for  wishing  cases  of  a  class  to  which 
they  have  been  accustomed,  or  for  which  they  have  tried 
to  especially  prepare  themselves ;  but  the  practice  of 
some  of  refusing,  sometimes  in  an  offensive  way,  to 
take  anything  unless  they  can  get  exactly  what  they 
wish,  usually  shows  weakness  of  character,  which  will 
interfere  with  full  success  in  their  vocation. 

Let  me  give  here  the  views  of  a  patient  whom  I 
asked,  both  because  of  her  unusual  intelligence  and 
her  experience  with  nurses  as  a  patient,  to  give  me 
her  idea  as  to  what  should  be  said  to  a  nurse  just 
starting  on  her  career.  The  physician  has  his  point 
of  view,  the  patient  has  his  or  hers,  and  by  combining 
and  comparing  both  the  nurse  will  perhaps  get  a  clear 
conception  of  what  the  world  thinks  and  expects 
of  her. 

"  As  the  nurse  is  about  to  start  out  on  her  own  re- 
sponsibility and  merits,  let  her  realize  that  she  is  now 
a  business  woman,  and  a  part  of  a  great  profession, 
and  she  should  never  let  herself  drift  from  this  reali- 
zation. She  should  take  the  very  highest  view  of  her 
work  and  stick  to  it  through  everything.  She  will 
then  not  only  do  a  high  grade  of  work,  but  will  avoid 


20  THE  NURSING  AND   CARE   OF 

many  difficulties  of  which  she  knows  nothing  when 
starting  out.  And  the  highest  view  of  her  work  is 
this,  that  she  is  to  help  fight  disease.  When  she  goes 
to  a  case  it  should  make  no  difference  to  her  whether 
the  patient  is  a  man,  woman,  or  child ;  whether  rich 
or  poor,  ignorant  or  educated.  She  should  let  no  per- 
sonal consideration,  aside  from  doing  good  work,  creep 
into  her  ambition.  When  she  is  at  work  her  patient's 
welfare  comes  first,  and  her  ultimate  recovery  is  the 
goal  towards  which  all  the  nurse's  efforts  should  be 
directed.  No  false  idea  of  what  is  suitable  to  her 
position  should  stand  in  her  way  to  mar  her  singleness 
of  purpose.  Whatever  is  for  the  patient's  good  is 
suitable  for  the  nurse  to  do. 

"  One  of  the  best  nurses  I  ever  knew,  and  it  is  need- 
less to  say  a  successful  one,  worked  with  her  patient 
for  weeks  on  a  farm  at  every  variety  of  farm-work. 
She  became  quite  skilled  in  handling  a  spade,  and 
many  a  night  went  to  bed  with  an  aching  back  after 
hours  of  weeding,  and  she  did  it  all  in  a  manner  that 
inspired  interest  and  pleasure  in  the  work.  This 
nurse  was  a  strict  observer  of  all  forms  of  professional 
etiquette,  but  had  a  broad  enough  view  of  her  work  to 
be  willing  to  hoe  a  row  of  corn  as  well  as  to  adminis- 
ter a  dose  of  the  more  usual  kinds  of  medicine. 

"  If  her  work  becomes  uninteresting  or  monotonous, 
the  nurse  may  be  sure  that  one  of  two  things  has 
taken  place.  Either  she  is  tired  and  needs  a  rest  and 
change,  or  she  is  not  working  intelligently.  A  Ger- 
man philosopher  says  that  the  world  is  a  mirror,  and 
if  a  donkey  looks  into  it  he  cannot  expect  to  see  the 


THE  NERVOUS  AND   THE  INSANE.  21 

face  of  a  sage  looking  out  of  it;  and  this  can  always 
be  applied  to  ourselves.  One  gets  out  of  his  work 
what  he  puts  into  it. 

"  It  is  important  never  to  deviate  from  a  strictly 
professional  relationship  towards  a  patient  and  the 
household  into  which  the  nurse  may  enter.  She  can 
be  the  cause  of  much  inconvenience  and  discomfort 
in  a  family,  and  herself  be  most  unhappy,  if  she  has 
a  mistaken  view  of  her  own  position.  She  is  there 
for  a  definite  purpose,  which  should  occupy  her  whole 
attention,  and  she  should  not  be  concerned  with  any- 
thing outside  of  this." 

Within  the  last  few  years  a  new  field  has  been  opened 
up  to  the  nurse  :  that  of  social  service  work.  For  this 
purpose  the  special  training  obtained  by  a  few  months' 
experience  in  a  hospital  for  mental  diseases  is  desirable. 
There  are  a  number  of  obsessed  persons,  psychasthenic 
and  neuropathic  individuals  who  may  be  cared  for  at 
home.  Under  good  hygiene  in  general  and  good  men- 
tal hygiene  in  particular,  such  persons  may  be  almost 
or  quite  self-supporting.  In  others  who  may  be  dis- 
charged from  insane  hospitals  before  completely  recov- 
ered, but  in  whom  further  detention  is  undesirable,  the 
"  follow-up  "  plan  is  a  most  fruitful  field  for  the  nurse 
with  this  special  training. 

I  shall  now  briefly  consider  the  management  of  hys- 
teria and  epilepsy.  These  are  two  of  the  most  important 
functional  diseases  of  the  nervous  system,  and  their 
nursing  and  treatment  call  for  the  exercise  of  unusual 
skill  and  discrimination.  First,  before  all,  let  me  cau- 
tion the  nurse  not  to  make  the  diagnosis  of  hysteria. 


22  THE  NURSING  AND   CARE  OF 

Even  physicians  of  large  experience  sometimes  find  it 
difficult  to  make  a  correct  diagnosis  in  alleged  hysteria, 
and  it  is  a  source  of  either  amusement  or  amazement 
to  me  to  see  the  self-confident  nurse  glibly  pronounce 
a  patient  that  she  has  seen  perhaps  once  or  twice  as 
hysterical,  or  as  an  hysterical  fraud.  On  the  whole, 
I  would  advise  the  nurse  never  to  use  the  word  hys- 
teria at  all.  To  be  hysterical  is  certainly  not  a  disgrace ; 
it  is  a  condition  into  which  the  best  of  women,  or, 
indeed,  of  men,  may  fall ;  but  the  idea  which  hysteria 
conveys  to  the  common  mind  is  too  often  that  of  sham- 
ming or  fraud.  Nine  patients  out  of  ten  will  feel  that 
they  are  insulted  if,  in  the  midst  of  nervous  suffering, 
they  are  called  hysterical. 

It  is  a  foolish  thing  in  a  nurse  who  has  charge  of  a 
patient  suffering  with  hysteria  to  give  way  to  every 
whim  and  fancy  of  the  patient ;  and  yet,  on  the  other 
hand,  she  cannot  by  denunciation  or  harsh  measures  get 
rid  of  the  inconvenience  and  care  which  such  patients 
may  give  her.  She  should  not  do  too  much  on  her  own 
responsibility  in  the  way  of  severe  treatment.  The  nurse 
may  be  called  up  three  or  four  times  during  a  night,  or 
in  some  other  way  may  be  sorely  tried,  but  all  that  she 
can  do  is  to  be  watchful  and  careful,  and  if  she  finds 
that  a  patient  is  disposed  to  make  things  uncomfortable, 
by  some  mild  but  positive  words  or  measures  try  to 
prevent  her.  She  must  not,  as  has  been  done  in  some 
cases,  plunge  the  patient  into  a  cold  bath  without  direc- 
tions from  a  physician.  The  one  to  use  threats  and 
severe  measures,  if  these  are  resorted  to  at  all,  is  the 
physician. 


THE  NERVOUS  AND  THE  INSANE.  23 

Jt  may  be  a  question  sometimes  whether  a  patient 
is  suffering  from  a  hysterical  or  from  an  epileptic  fit, 
and  this  doubt  is  not  always  easy  of  solution,  although 
usually  the  two  affections  can  be  separated.  Hysterical 
seizures  differ  in  character.  Sometimes  they  are  pur- 
posive or  voluntary, — ^that  is,  they  are  completely  under 
the  control  of  the  patient,  by  whom  they  are  induced 
or  feigned ;  at  other  times  they  are  as  completely  be- 
yond the  control  of  the  will  as  are  the  convulsions  of 
epilepsy.  The  simulated  or  foolish  fits  of  hysteria  can 
generally  be  recognized.  The  screaming,  shouting,  and 
violent  movements  of  the  patient,  at  the  same  time 
that,  perhaps,  she  can  be  discovered  closely  watching 
others,  will  put  the  physician  or  nurse  on  guard. 

Some  of  the  involuntary  hysterical  attacks,  the  par- 
oxysms of  hystero-epilepsy  so  called,  closely  resemble 
true  epilepsy.  These  attacks  are  in  some  respects  grave, 
although  they  are  not  either  as  incurable  or  as  tempo- 
rarily dangerous  to  life  as  genuine  epilepsy.  In  the 
purposive  or  simulated  hysterical  fits  consciousness  is 
never  lost.  In  the  hystero-epileptic,  or  grave  hysterical 
attack,  however,  it  is  not  strictly  true  to  say  that  loss 
of  consciousness  does  not  take  place.  It  does  occur, 
but  there  is  a  difference  between  the  loss  of  conscious- 
ness in  epilepsy  and  that  in  hystero-epilepsy.  The 
question  of  consciousness  is  one  of  grade  and  degrees. 
A  patient  may  be  more  or  less  unconscious.  In  epilepsy 
the  unconsciousness  is  complete,  profound,  and  per- 
sistent. In  hystero-epilepsy  consciousness  is  lost  com- 
pletely during  only  a  short  phase  of  the  attack.  The 
hysterical  or  hystero-epileptic  patient  rarely  bites  the 


24  THE   NURSING    AND    CARE   OF 

tongue,  while  this  accident  commonly  happens  in  epi- 
lepsy. I  have  observ^ed  in  hystero-epileptic  cases 
that  whether  the  patient  is  or  is  not  responsive  to  ex- 
ternal impressions  the  countenance  usually  retains  an 
unusual  placidity.  On  one  occasion,  at  the  German 
Hospital  in  Philadelphia,  I  watched  for  more  than  two 
hours  the  frightful  contortions  of  a  typical  hystero- 
epileptic  ;  and,  although  during  this  long  period  she  got 
into  almost  every  imaginable  grotesque  and  extraordi- 
nary position,  during  all  the  time  her  countenance  re- 
mained as  placid  as  a  summer  morning. 

A  nurse,  or  even  a  physician,  sometimes  make«  a 
mistake  with  reference  to  the  diagnosis  between  an  epi- 
leptic and  an  hystero-epileptic  seizure  through  igno- 
rance of  the  fact  tliat  sometimes  the  patient  is  the  victim 
of  both  hysteria  and  epilepsy.  A  patient  so  afflicted 
is  sometimes  designated  as  a  case  of  hystero-epilepsy, 
with  separate  crises.  In  the  wards  for  diseases  of  the 
nervous  system  in  the  Philadelphia  Hospital  was  a 
female  patient  who  has  had  at  long  intervals  well-marked 
epileptic  seizures,  accompanied  by  profound  unconscious- 
ness with  biting  of  the  tongue.  In  addition,  however, 
at  more  frequent  intervals  she  had  had  violent  hysterical 
outbreaks.  In  such  a  case  as  that  the  nurse  who  is  not 
well  informed  about  such  matters  might  readily  make 
a  mistake. 

The  nurse  should  have  a  clear  idea  of  the  character- 
istics of  a  genuine  epileptic  seizure.  Usually  such  an 
attack  comes  on  very  suddenly,  often  preceded  by  a  cry 
of  pain  or  great  fright.  The  patient  falls  suddenly  with 
great  force,  sometimes  in  the  most  dangerous  places. 


THE  NERVOUS  AND  THE  INSANE.  25 

Convulsions  then  begin.  Usually  they  are  at  first  what 
ib'  termed  tonic, — that  is,  the  limbs  and  body  become 
rigid  and  immovable  in  certain  positions.  Then  the 
so-called  clonic  movements  occur, — that  is,  the  patient 
is  violently  twisted,  contorted,  and  tossed  about.  Fre- 
quently these  movements  begin  in  one  limb  or  part  and 
extend  raj)idly  until  all  portions  of  the  body  are  in- 
volved, and  the  convulsion  becomes  general.  The  face, 
at  first  pale,  changes  to  red,  gray,  or  purple,  or  becomes 
absolutely  livid  ;  or  alternates  between  pallor,  flushing, 
or  livid  ity  ;  the  p\4pils  are  dilated  and  fixed ;  the  eyes 
are  frequently  turned  upwards ;  the  patient  froths  at 
the  mouth,  ejecting  often  a  mixture  of  saliva  and  biood. 
The  tongue  is  bitten  generally  early  in  the  seizure.  The 
breathing  is  irregular  and  sometimes  stertorous.  The 
attacks  vary  in  length,  always  seeming  longer  than  they 
are,  usually  not  lasting  more  than  a  few  minutes  at 
most.  As  the  convulsive  movements  cease  the  patient 
sometimes  becomes  semi-conscious,  but  continues  much 
dazed,  or  more  commonly  falls  into  a  profound  stupor. 
Sometimes  urine  is  passed  unconsciously,  or  the  bowels 
are  involuntarily  evacuated.  The  pulse  shows  great 
variations. 

When  satisfied  that  a  patient  is  suffering  from  an  epi- 
leptic attack,  it  is  important  not  to  be  too  meddlesome. 
More  harm  may  be  done  by  unnecessary  interference 
than  by  comparative  neglect.  It  is  important,  however, 
that  a  person  in  an  epileptic  fit  should  be  watched.  If 
the  clothing  is  binding  anywhere,  it  should  be  loosened. 
The  patient  should  be  placed  so  as  to  have  as  little 
injury  as  possible  result  from  the  violent  movement. 


26  THE  NURSING  AND    CARE  OF 

It  is  better  to  have  the  head  slightly  elevated.  If  the 
room  is  close,  fresh  air  should  be  allowed  to  enter  it  in 
abundance.  It  is  not  well  to  roughly  seize  and  hold  the 
patient,  or  to  force  open  the  clinched  hands  with  great 
effort.  It  is  not  always  best  to  make  great  efforts  to  open 
the  mouth  by  means  of  a  towel,  or  wedge,  or  bandage. 
The  object  of  this  would  be  to  prevent  the  patient  from 
biting  the  tongue,  and  as  this  commonly  occurs  early 
in  the  seizure,  the  mischief  will  usually  have  been  done 
before  the  treatment  can  be  applied.  Here,  as  in  so 
fnany  other  cases,  no  fixed  rule  applies ;  but  good  sense 
iiud  quick  wit  come  into  play. 

An  epileptic  attack  cannot  be  aborted  by  brute  force. 
Sometimes  epileptics  have,  preceding  the  paroxysm, 
what  is  termed  an  aura, — that  is,  a  peculiar  feeling  in 
some  part  of  the  body.  It  may  be  the  sensation  of  a 
vapor  passing  up  a  limb,  or  a  feeling  of  crawling,  or  a 
sharp  pain.  When  it  is  known  that  such  a  sensation 
is  felt  at  the  extremity  of  a  limb  at  each  recurrence  of 
the  seizure,  if  the  nurse  is  at  hand  the  attack  may 
sometimes  be  stopped  by  seizing  and  tightly  holding 
the  limb  above  the  point  where  the  aura  begins.  If 
with  a  patient  known  to  be  an  epileptic,  the  nurse 
should  see  to  it  that  the  patient  is  never  in  any  un- 
necessary danger ;  clothing  should  be  worn  a  little  loose, 
and  the  patient  should  be  guarded  from  danger  from 
fire  or  machinery. 

Independently  of  the  management  of  the  paroxysm, 
a  number  of  important  practical  points  in  connection 
with  the  general  care  of  patients  suffering  from  epilepsy 
are  worthy  of  consideration.     Before  or  after  couvul- 


THE  NERVOUS  AND   THE  INSANE.  27 

sion,  and  sometimes  in  the  place  of  such  an  attack, 
epileptics  sometimes  pass  into  peculiar  abnormal  mental 
states.  These  may  vary  from  a  state  in  which  the 
patient  is  simply  dazed,  confused,  or  dull,  to  an  attack 
of  acute  mania.  The  nurse  knowing  this  should  be 
on  the  guard  to  prevent  harm.  Each  patient  should 
be  carefully  studied,  and  his  or  her  peculiarities  noted. 
Purposeless  irritability  and  excitement,  which  are  at- 
tributed sometimes  by  physicians  and  nurses  to  ill- 
temper,  are  really  often  the  result  of  disease ;  and  so 
likewise  are  states  of  suspicion  and  distrust.  The  diet 
in  cases  of  epilepsy  should  be  carefully  attended  to,  as 
epileptics  are  likely  to  be  large  eaters.  They  seem 
sometimes  to  require  large  amounts  of  food  ;  but  they 
can  easily  eat  too  much.  The  amount  and  character 
of  food  are  of  course  to  be  directed  by  the  physician  in 
charge,  but  to  the  nurse  or  attendant  the  carrying  out 
of  these  directions  must  necessarily  be  intrusted.  Ob- 
servations made  by  some  good  authorities  strongly  favor 
a  vegetable  diet  in  epilepsy,  and  when  such  diet  is 
ordered,  the  nurse  should  see  that  it  is  rigidly  adhered 
to  according  to  directions.  What  is  known  as  the  purin- 
free  diet  has  proved  in  my  experience  one  of  the  best 
in  most  cases  of  epilepsy.  Dr.  Wm.  Aldren  Turner  in 
his  work  on  epilepsy  gives  the  following  list  of  articles 
as  the  best  out  of  which  to  get  such  a  diet :  Milk,  eggs, 
butter,  cheese,  rice,  macaroni,  tapioca,  white  bread,  cab- 
bage, lettuce,  cauliflower,  sugar,  and  fruit,  both  fresh  and 
dried,  and  olive  oil.  (Turner,  Wm.  Aldren. — '^Epi- 
lepsy. A  Study  of  the  Idiopathic  Disease,"  p.  246.) 
Overloading  of  the  stomach  and  prolonged  constipation 
sometimes  lead  to  the  attacks;  these  should  be  prevented. 


28  THE  NURSING  AND   CARE  OF 

Some  epileptics  show  special  features  requiring  par- 
ticular attention.  One  may  have  a  recurrently  dislocat- 
ing shoulder ;  others  may  have  a  tendency  to  run  away. 

It  is  desirable  that  more  extensive  records  be  kept 
of  these  individuals,  as  the  fit  is  but  a  small  part  of  the 
epileptic^s  phenomena. 

Epileptics  should  never  be  allowed  to  bathe  alone ; 
they  have  been  known  to  drown  in  a  bath-tub  with 
only  a  few  inches  of  water. 

Since  epileptic  children  are  not  allowed  in  the  public 
schools  excepting  in  special  classes  and  but  few  of  the 
adults  are  able  to  hold  positions,  they  are  best  cared 
for  on  colony  farms,  but  of  course  the  well-to-do  may 
be  provided  for  at  home.  About  10  per  cent,  at  times 
have  insane  periods  and  because  of  this  they  may  require 
detention  in  insane  hospitals.  Epileptic  insanities  are 
precipitate  and  dangerous. 

The  rules  and  regulations  in  force  at  the  Craig  Colony 
for  Epileptics  at  Sonyea,  N.  Y.,  are  in  part  given  here : 

Duties  op  Nukses  and  Attendants. 

Nurses  must  hold  diplomas  showing  them  to  be  graduates 
from  a  recognized  training  school  for  nurses,  and  because  of 
their  superior  advantages  and  training  they  will  receive  greater 
compensation  than  is  paid  to  attendants,  performing,  at  the 
same  time,  work  and  assuming  responsibilities  which  attendants 
may  not  be  qualified  to  perform  or  assume. 

Nurses  should  constantly  set  attendants  worthy  examples  of 
industry,  efficiency,  neatness,  punctuality  and  faithfulness,  in 
the  discharge  of  all  duties  to  the  sick. 

The  first  object  of  all  nurses  and  attendants  must  be  the  wel- 
fare of  the  patients,  and  in  all  their  intercourse  with  patients, 
they  must  treat  them  with  respect  and  civility,  address  them 
mildly  and  kindly,  and  avoid  rudeness  and  violence  of  any  kind. 
Nurses  and  attendants  are  to  avoid  any  exhibition  of  temper, 


THE  NERVOUS  AND  TEE  INSANE.  29 

and  never  scold,  threaten  or  command  authoritatively,  but 
whenever  they  desire  anything  done  by  a  patient,  make  the 
request  in  a  respectful  manner. 

In  the  care  of  epileptics  kindness  and  tact  must  always  take  the 
place  of  force  and  display  of  authority.  Epileptics  can  be  governed 
by  mild  and  kindly  measures  far  better  than  by  fear  and  force. 

A  blow  is  never  to  be  iriflicted  on  a  patient  by  an  employee  un- 
der any  circumstances.  Any  violation  of  this  rule  will  subject 
the  offender  to  instant  dismissal. 

Whenever  a  patient  is  excited,  violent  and  destructive,  as  is 
so  frequently  the  case  with  them  just  before,  during,  or  after  a 
seizure,  and  then  it  becomes  necessary  for  a  nurse  or  attendant 
to  hold  and  restrain  the  patient  to  prevent  him  from  injuring 
himself  or  others,  they  will  be  careful  never  to  use  undue  force  ; 
never  to  kneel  on  a  patient's  chest ;  never  to  grasp  the  patient 
by  the  neck  or  throat,  but  endeavor  to  exercise  the  needful 
restraint  by  grasping  the  patient  about  the  body  and  holding  his 
arms  to  his  side,  if  possible,  standing  immediately  behind  the 
patient  for  the  purpose.  Nurses  and  attendants  are  cautioned 
against  trying  to  restrain  violent  patients  alone,  and  in  every 
case  possible,  they  must  call  some  one  to  assist  them. 

Nurses  or  attendants  must  never  restrain  or  confine  a  patient 
in  a  room  without  direction  of  a  medical  officer.  All  persons 
employed  in  the  care  of  patients  are  cautioned  to  be  on  their 
guard  against  acts  of  violence  on  the  part  of  the  patients,  and 
must  be  careful  to  see  that  dangerous  weapons  are  not  carried 
by  patients  who  are  subject  to  violent  outbreaks. 

Nurses  and  attendants  must  never  allow  patients  to  be  laughed 
at,  ridiculed  or  harshly  spoken  to  on  account  of  peculiarities  of 
behavior.  New  patients  must  always  receive  special  attention. 
The  first  effect  of  being  in  so  novel  a  place,  where  the  restrictions 
are  greater  than  at  home,  is  to  make  many  patients  apprehensive 
of  harm,  and  their  fears  should  be  quieted.  The  rules  of  the  house 
should  be  explained;  the  patients  should  be  invited  to  their  meals, 
and  be  told  at  bed  time  that  the  night  watch  or  nurse  will  visit 
them.  Every  effort  should  be  made  by  the  nurse  or  attendant  to 
relieve  anxiety  and  show  kindly  attention  to  the  newcomer. 

One  nurse  or  attendant  or  other  responsible  person  must  always 
be  present  with  the  patients  in  the  houee. 

Nurses  and  attendants  must  rise  promptly  at  the  signal  for 


30  THE  NURSING  AND    CARE   OF 

rising,  and  immediately  commence  the  labors  of  the  day.  They 
will  see  that  all  patients  are  up  ;  that  all  are  properly  dressed, 
washed  and  prepared  for  breakfast. 

All  patients  who  are  not  taking  their  food  or  medicine,  all  cases 
of  violence  or  blows,  or  of  illness  will  be  reported  to  the  physician. 

Nurses,  attendants  or  other  employees  are  forbidden  to  use  or 
wear  articles  belonging  to  patients. 

The  first  object  of  all  employment  of  patients  must  be  the  bene- 
fit of  the  patient.  Nurses  and  attendants  must  not  grant  any 
special  or  unusual  privilege  to  any  patient,  except  as  authorized 
by  a  medical  officer,  and  they  will  take  care  that  clothing  worn 
by  patients  is  adapted  to  the  season  and  the  occasion. 

Under  clothing  is  to  be  changed  twice  weekly  when  patients 
are  bathed,  and  of  tener  when  required. 

Soiled  clothing  is  not  to  be  left  in  a  patient's  room.  When 
patients  soil  their  clothing,  it  is  to  be  immediately  changed. 
All  patients  must  be  constantly  and  neatly  clad,  as  far  as  re- 
sources permit. 

Attendants  must  be  personally  present  at  the  bathing  of  the  pa- 
tients; especially  important  is  this  in  the  case  of  the  feeble.  The  at- 
tendant will  see  that  the  water  of  the  bath  has  the  proper  tempera- 
ture. Bathroom  doors  are  always  to  be  kept  locked  when  not  in.  use. 

Not  only  shall  nurses  and  attendants  supervise  the  work  of 
patients,  but  they  shall,  themselves,  when  necessary,  take  the 
initiative  in  all  kinds  of  labor. 

Male  patients  are  to  be  shaved  twice  weekly,  or  oftener  if 
required.  In  shaving,  great  care  is  to  be  used  to  have  the  razor 
in  good  order.  No  patient  shall  be  permitted  to  shave  himself 
unless  by  order  of  a  medical  officer.  Hair  and  nails  must  be 
cared  for  by  the  nurse  when  patient  is  unable  to  do  so. 

When  patients  are  unable  to  attend  the  dining  room,  the  nurse 
or  attendant  must  personally  see  that  their  food  is  properly 
served  to  them.  Special  diet  should  always  be  ordered  by  the 
physician  and  must  always  be  given  to  the  person  for  whom  it 
is  ordered.  A  nurse  or  attendant  shall  be  in  each  dining  room 
when  patients  are  at  meals. 

Patients  who  are  in  a  low  or  critical  condition  shall  always  have 
someone  in  immediate  attendance  upon  them,  and  must  not  be  left 
alone.  Such  patients  shall  not  be  taken  up  for  changing  of  cloth- 
ing or  bathing  without  directions  from  a  physician. 


THE  NERVOUS  AND  THE  INSANE.  31 

Keys  mHst  be  used  by  nurses  or  attendants.  Tbey  are  not  to 
be- left/ carelessly  about,  nor  intrusted  to  patients. 

Patients  must  not  be  allowed  to  lie  down  on  the  cold,  damp 
ground,  nor  walk  on  or  near  the  railroad  tracks,  nor  go  bathing. 

Patients  in  Infirmaries  who  are  able  to  walk,  must,  when  the 
weather  permits,  be  taken  out  of  doors  twice  daily. 

Nurses  and  attendants  will  not  receive  visitors  in  the  cottages, 
except  by  permission  of  a  medical  officer,  nor  shall  they  allow 
persons  about  the  cottages  who  have  not  a  right  to  be  there. 

Nurses  and  attendants  must  avoid  expressing  opinions  on  the 
condition  of  patients  to  relatives  and  friends,  referring  all  such 
inquiries  to  the  physician.  Nor  shall  they  correspond  with 
patients'  relatives  concerning  the  condition  of  patients,  and 
when  they  get  letters  of  inquiry  about  patients,  they  will  refer 
such  letters  to  the  Superintendent. 

All  night  nurses  and  attendants  shall  wear  noiseless  shoes 
when  on  duty. 

In  a  few  cases  it  may  be  important  for  the  nurse  to  be 
able  to  diagnosticate  the  cause  or  nature  of  insensibility, 
of  other  forms  than  that  seen  in  epilepsy.  While  diagno- 
sis is  the  duty  of  the  physician,  a  little  exact  knowledge  of 
a  disease  or  condition  may  enable  a  nurse  to  so  act  in  an 
emergency  before  the  doctor  arrives,  or  when  he  cannot 
come,  as  to  give  the  patient  a  better  chance  of  ultimate 
recovery,  or  possibly  even  to  save  life.  The  nurse  should 
have  some  general  idea  how  to  distinguish  not  only  as  to 
whether  a  patient  is  either  drunk  or  stricken  with  apo- 
plexy, but  also  whether  he  or  she  may  be  suffering  from 
the  effects  of  some  narcotic  poisoning ;  from  what  is 
termed  uraemia,  a  condition  in  which  the  blood  becomes 
surcharged  with  matters  which  should  be  excreted  by  the 
kidneys;  or  whether  again  those  conditions  which  prevail 
in  sunstroke,  heat-exhaustion,  or  fainting  are  present. 

If  we  are  able  to  recognize  at  once  that  a  patient  is 
suffering  from  an  apoplexy,  particularly  what  is  termed 


32  THE  NURSING  AND    CARE   OF 

a  hemorrhagic  apoplexy,  iii  which  blood  from  a  broken 
vessel  is  poured  out  into  the  brain-substance,  that  pa- 
tient may  be  so  handled  as  to  give  him  a  chance  for  life 
and  approximate  recovery.  The  treatment  is  chiefly  a 
negative  one,  but  this  negative  treatment  is  of  great 
importance.  If  such  a  patient  is  jarred  and  moved 
about,  is  carried  from  pillar  to  post,  is  twisted  and 
turned  in  order  to  remove  clothing  or  for  other  pur- 
poses, the  hemorrhage  may  be  unnecessarily  increased. 
In  some  cases  of  apoplexy,  a  comparatively  small 
hemorrhage,  from  a  small  blood-vessel,  will  cause 
great  shock  and  complete  unconsciousness,  and  the 
bleeding  in  such  a  case  may  have  a  tendency  to  stop  if 
the  patient  is  kept  absolutely  quiet.  Indirectly,  too, 
the  danger  is  augmented  by  unnecessary  movement  ex- 
citing the  heart  and  general  circulation.  Even  when 
apoplexy  is  not  of  the  hemorrhagic  variety,  quietness 
should  be  the  rule.  The  stertorous  or  noisy  breathing 
so  often  observed  in  cases  of  apoplexy,  and  in  some 
forms  of  insensibility  due  to  other  causes,  is  some- 
times a  sign  of  danger  and  is  always  a  distressing 
symptom.  An  English  physician  named  Bowles  be- 
lieved that  stertorous  breathing  is  usually,  if  not 
always,  due  to  mechanical  causes,  which  may  be  re- 
lieved in  whole  or  in  part  by  attention  to  the  position 
of  the  insensible  patient.  The  tendency  of  a  patient 
suffering  from  apoplexy  is  to  lie  on  his  back.  In  this 
position  stertor  is  usually  very  marked.  By  turning 
the  patient  on  his  side,  according  to  Bowles,  and  I 
have  on  a  number  of  occasions  confirmed  his  views, 
the  stertor  often  disappears  or  is  greatly  relieved.     If 


THE  NERVOUS  AND    THE  INSANE.  33 

the  patient  is  paralyzed,  as  is  usually  the  case,  when 
suffering  from  an  apoplectic  attack,  he  should  by  pref- 
erence be  turned  on  or  towards  the  paralyzed  side. 
If  the  breathing  is  not  at  once  relieved,  some  adjust- 
ment of  the  face  and  head  may  bring  about  this  favor- 
able result.  A  completely  unconscious  patient  will, 
as  a  rule,  tend  to  gravitate  again  to  the  position  on  the 
back,  and  this  can  be  prevented  by  carefully  propping 
him  with  pillows,  bolsters,  or  blankets.  In  turning  the 
patient  from  the  back  to  the  side,  the  nurse  or  nurses 
should  be  careful  to  jar  the  patient  as  little  as  possible. 

If  the  patient  is  suffering  from  drunkenness,  or  is 
narcotized  by  opium  or  some  other  powerful  drug,  it 
may  be  all-important  to  promptly  arouse  and  excite 
the  dormant  nervous  system ;  and  this  is  particularly 
true  in  cases  of  narcotic  poisoning. 

It  is  for  this  reason  that  applications  of  electricity 
or  even  slapping  or  otherwise  irritating  the  patient  may 
be  of  service  in  cases  of  narcotism,  but  such  treatment, 
as  already  stated,  would  be  not  only  useless  but  dan- 
gerous in  a  case  of  apoplexy,  in  which  the  rule  should 
be  to  keep  the  patient  as  quiet  as  possible,  at  least  until 
the  acute  attack  is  over. 

It  is  by  no  means  easy  even  for  a  physician  well 
trained  in  his  art  to  make  a  diagnosis  in  these  cases, 
and  therefore  a  nurse  who  should  fail  is  not  always  to 
be  held  to  rigid  accountability.  The  nurse  should,  how- 
ever, be  able  to  distinguish  those  cases  in  which  the 
diagnosis  is  comparatively  clear.  The  rarity  of  convul- 
sions without  heart- failure ;  flushing  of  the  face  or  more 
rarely  pallor ;  stertorous  breathing ;  slow  and  full  pulse  ; 

3 


34  THE  NURSING   AND    CARE   OF 

pupils  fixed  and  one  or  both  dilated ;  paralysis  of  one 
side ;  retention  or  involuntary  passage  of  urine ;  tem- 
perature at  first  lowered,  and,  as  a  fatal  issue  approaches, 
rapidly  rising,  are  some  of  the  points  usually  given. 
These  are  good,  and  correct  as  far  as  they  go,  but  some 
details  as  to  the  determination  of  these  facts  may  be 
given,  and  a  few  points  may  be  added.  A  nurse 
should  know  something  of  the  methods  of  determining 
whether  a  patient  is  paralyzed  upon  one  side.  Glancing 
carefully  at  the  patient^s  face,  usually,  but  not  invari- 
ably, one-half  of  the  face  will  seem  to  droop,  or  will 
be  twisted  toward  the  other  side ;  the  angle  of  the  mouth 
on  the  paralyzed  side  will  perhaps  be  a  little  lower,  and 
the  lines  and  contours  will  be  somewhat  smoothed  out. 
Lifting  the  arm,  first  to  one  side  and  then  to  the  other, 
the  paralyzed  extremity  will  fall  limp  and  flail-like, 
while  the  extremity  of  the  unaffected  side  will  usually 
convey  a  certain  resistance  to  the  examiner,  even  though 
the  patient  be  totally  unconscious.  The  same  conditions 
can  usually  be  determined  by  a  cautious  manipulation 
of  the  legs.  The  respiration  is  not  only  heavy  and 
stertorous,  but  it  is  frequently  also  what  is  called 
"  Cheyne-Stokes'^  in  character, — that  is,  the  breathing 
becomes  less  and  less  marked,  descending  until  the  pa- 
tient does  not  seem  to  breathe  at  all ;  then,  after  a  few 
seconds,  beginning  again  and  gradually  becoming  more 
positive.  It  is  an  ascending  and  descending  respiration, 
— a  respiration  with  a  break  or  gap.  Another  condi- 
tion, called  conjugate  deviation  of  the  eyes  and  head, 
very  commonly  present  in  cases  of  one-sided  apoplexy, 
can  be  determined  by  simply  looking  at  the  patient 


THE   NERVOUS  AND    THE  INSANE.  35 

The  eyes  constantly  turn  or  tend  to  turn  to  one  side, 
and  the  head  also  shows  the  same  tendency.  Usually, 
the  direction  is  away  from  the  side  of  the  paralysis. 

If  satisfied  that  the  patient  has  had  an  apoplectic  at- 
tack, or  if  in  doubt  about  the  matter,  it  is  wise,  as  has 
been  already  intimated,  to  keep  him  as  quiet  as  possible. 
The  clothes  should  be  loosened  so  that  no  undue  press- 
ure will  be  exerted  anywhere  upon  the  blood-vessels 
or  internal  organs ;  but  great  caution  should  be  exer- 
cised in  the  way  in  which  the  clothing  is  handled.  It 
is  sometimes  far  better  to  cut  and  destroy  clothing  than 
to  move  the  patient  unnecessarily  in  removing  or  loosen- 
ing it.  Warmth,  and  even  counter-irritation,  may  be 
safely  applied  to  the  extremities ;  cold  to  the  head  is 
usually  indicated,  but  sometimes  is  better  not  employed, 
particularly  when  there  is  great  general  depression  of 
temperature.  As  a  rule,  a  nurse  should  not  take  the 
responsibility  of  administering  medicines  in  such  cases. 
Certainly  emetics  should  not  be  given  without  orders. 

/^Probably  the  only  medicine  which  a  nurse  would  be 
fully  justified  in  administering  on  her  own  responsi- 

»,     bility  would  be  a  purgative,  like  one  or  two  drops  of 
xroton  oil  in  sweet  oil. 

Some  knowledge  of  the  conditions  present  and  the 
treatment  called  for  in  case  of  sunstroke  or  heat-pros- 
tration is  essential.  This  affection  may  be  caused  not 
only  by  exposure  to  the  sun,  but  by  intense  heat,  par- 
ticularly with  fatigue.  The  danger  is  usually  very 
great.  One  of  two  conditions  may  arise  :  thermic  fever, 
or  heat  exhaustion.  The  onset  of  thermic  fever  is  usu- 
ally by  headache,  nausea  and  vomiting,  a  stuporous 


36  THE  NURSING  AND    CARE  OF 

condition  supervenes  and  the  temperature  may  run  to 
the  extreme  height  of  110°  F.;  the  face  is  flushed,  the 
pulse  is  rapid  and  respiration  is  labored ;  the  pupils 
are  contracted. 

An  abundance  of  fresh  air  should  be  supplied  and 
the  patient  sponged  with  cold  water  or  rubbed  with  ice. 
Ice  water  enemas  may  be  given.  If  the  condition  be 
one  of  exhaustion,  consciousness  is  retained,  the  skin  is 
clammy,  the  pulse  feeble,  the  respirations  shallow  and 
rapid.  The  patient  should  be  covered  and  hot  bottles 
applied.  Stimulation  is  needed  in  the  form  of  black 
coffee,  whiskey,  or  aromatic  spirit  of  ammonia,  but 
these  should  not  be  used  without  medical  advice. 

It  is  not  always  an  easy  matter  to  tell  that  a  patient 
is  dead  drunk.  A  patient  may  smell  of  alcohol  and 
yet  be  suffering  from  an  apoplectic  attack.  He  may  be 
drunk  and  also  have  a  "  stroke."  In  the  Philadelphia 
Hospital  a  fair  percentage  of  the  cases  brought  in 
during  the  apoplectic  attack  have  been  drinking,  the 
excessive  use  of  liquor  acting  as  the  exciting  cause  in  an 
individual  whose  vessels  are  already  diseased.  What  are 
some  of  the  indications  of  genuine  intoxication  ?  Con- 
sciousness may  appear  to  be  lost,  but  this  loss  of  con- 
sciousness is  not  as  absolute  as  in  the  majority  of  cases 
of  apoplexy.  The  patient  can  generally  be  momen- 
tarily aroused  from  his  stupor,  if  it  is  only  to  sink  back 
again  with  a  grunt.  The  face  will  be  more  commonly 
flushed  than  pale ;  the  pupils  will  probably  be  equal, 
more  frequently  dilated ;  the  breathing,  although  heavy, 
is  not  strictly  speaking  stertorous,  nor  is  it  likely  to  be 
of  the  Cheyne-Stokes  variety.     The  temperature  may 


THE  NERVOUS  AND    THE  INSANE.  37 

be  below  the  normal  two  or  three  degrees,  but  it  does 
not'S'how  the  peculiar  variations  which  are  commonly 
present  in  genuine  apoplexy.  In  a  case  in  which,  in 
spite  of  examination  and  of  studying  the  points  here 
considered,  the  diagnosis  still  remains  doubtful,  it  is 
better  for  a  nurse  to  do  nothing  except  quietly  take 
care  of  the  patient  and  prevent  injury.  Dr.  Reginald 
Southey^  recommends  the  throwing  up  the  rectum,  by 
injection,  of  a  pint  and  a  half  of  cold  water,  with  a 
tablespoonful  of  common  salt  dissolved  in  it.  In  a 
case  of  extreme  drunkenness  this  brought  the  patient 
out  at  once.  If  carefully  administered  in  a  doubtful 
case,  it  would  certainly  be  less  likely  to  do  harm  than 
stomach-pumping,  or  galvanizing,  a  comatose  person. 

In  ursemic  coma — that  form  of  unconsciousness  from 
the  blood-poisoning  which  takes  place  because  diseased 
kidneys  cannot  properly  excrete  effete  matters  from  the 
ftystem — a  nurse  will  not  usually  be  able  or  expected 
to  determine  the  condition.  In  some  cases  of  ursemic 
coma,  however,  certain  evident  physical  conditions  will 
enable  almost  any  one  to  suspect  the  real  state  of  affairs. 
Such  a  patient,  for  example,  may  have  swelling  of  the 
limbs,  or  of  the  eyelids  or  face ;  a  condition  of  wax- 
like pallor  may  be  present;  the  breath  may  have  a 
urinous  or  beef-tea  odor ;  the  pupils  will  generally  be 
dilated ;  and,  as  a  rule,  but  not  without  exceptions,  one 
side  of  the  body  will  not  show  paralysis  more  than  the 
other.  When  a  patient  is  known  to  be  suffering  from 
ursemic  poisoning,  active  purgatives  and  measures  to 
produce  sweating,  as  warm  baths,  may  do  much  good. 

1  Lancet,  December  4,  1880. 


38  TEE  NURSING  AND    CARE   OF 

An  attack  of  fainting  is  ordinarily  not  dangerous  to 
life,  although  sometimes  attacks  which  look  like  a 
simple  faint  are  the  result  of  serious  disease  of  the 
heart  or  brain.  The  fainting  person  suddenly  becomes 
pale,  loses  consciousness,  and  usually  falls,  the  pulsa- 
tions of  the  heart  and  the  movements  of  breathing 
becoming  diminished.  In  a  faint  the  brain  is  com- 
monly deprived  temporarily  of  its  proper  supply  of 
blood.  The  individual  should  be  carefully  placed  on 
the  back,  and  the  clothes  loosened.  In  some  cases  it  is 
well  to  raise  the  body  and  limbs  a  little  above  the  level 
of  the  head.  In  this  way  the  circulation  will  be  given 
the  best  possible  chance  to  right  itself.  Sprinkling  cold 
water  on  the  face  and  applying  ammonia  to  the  nostrils 
and  heat  to  the  extremities  and  the  stomach  will  assist 
in  bringing  about  reaction. 

In  hospitals  in  which  cases  of  chronic  organic  disease 
of  the  nervous  system  are  treated,  as,  for  example,  in 
the  Nervous  Wards  of  the  Philadelphia  Hospital,  where 
sometimes  two  hundred  to  three  hundred  patients,  a 
majority  of  them  suffering  from  structural  affections 
of  the  brain  or  spinal  cord,  are  to  be  found,  it  is  im- 
portant that  the  nurse  should  have  clear  ideas  as  to  the 
special  care  of  those  suffering  from  paralysis  and  other 
forms  of  extreme  helplessness.  Sometimes  a  paralytic 
case,  and  a  ward  in  which  paralytics  are  found  in  large 
numbers,  are  regarded  as  uninteresting,  or  possibly  un- 
pleasant ;  but  to  a  faithful  nurse,  to  one  who  has  a  just 
idea  of  her  vocation,  these  helpless  people  should  be 
interesting  because  of  their  suffering.  Certainly,  few 
cases  of  chronic  diseases  call  for  so  much  true  sympathy ; 
certainly,  also,  in  few  are  the  opportunities  to  comfort 


THE  NERVOUS  AND    THE  INSANE.  39 

and  relieve  greater.  These  patients  are  sometimes  lit- 
erally unable  to  move  hand  or  foot,  or,  if  the  helpless- 
ness is  not  so  extreme  as  this,  they  are  paralyzed  either 
upon  one  side  or  in  the  lower  or  upper  half  of  the 
body,  more  commonly  the  former.  Sometimes  sensi- 
bility has  departed  from  their  limbs.  Sometimes  they 
suifer  from  contractures  to  such  an  extent  that,  as  with 
one  case  now  in  the  Philadelphia  Hospital,  they  are 
literally  tied  into  knots.  When  the  condition  is  not  so 
extreme  as  this,  the  limbs  may  be  flexed  upon  each 
other  and  upon  their  bodies  so  as  to  prevent  any  move- 
ment except  with  great  pain.  Frequently  paralysis  of 
the  bowels  or  bladder,  or  of  the  sphincter  of  the  bowels 
or  bladder,  is  present,  causing  involuntary  evacuation 
or  constant  retention  of  fsecal  matter  or  urine,  and 
adding  the  dangers  of  overdistention  and  even  rupture 
of  the  bladder. 

A  quick-witted,  efficient  nurse  will  soon  learn  from 
observation  and  contact  with  helplessness  how  to  be 
most  helpful.  In  such  matters  as  assisting  a  case  of 
one-sided  paralysis,  or  of  ataxia,  in  walking,  canes, 
crutches,  wheel-chairs,  and  the  like,  can  be  resorted  to, 
and  it  will  be  the  duty  of  the  nurse  to  see  that  they  are 
used  in  the  most  advantageous  manner.  Certain  little 
details  of  great  importance,  both  with  reference  to  the 
comfort  and  cleanliness  of  the  patients  and  of  the 
rooms,  will  need  attention.  When  the  patients  suffer 
from  paralysis  of  the  bowels  or  bladder,  the  nurse 
should  bear  in  mind  the  attendant  evils ;  should  pro- 
vide against  emergencies,  and  should  frequently  examine 
to  see  that  the  patients  are  not  in  a  filthy  condition. 


40  THE  NURSING  AND   CARE  OF 

Many  cases  of  organic  nervous  disease  suffer  from  in- 
flammation of  the  bladder,  secondary  to  the  paralysis 
of  that  organ  so  often  present.  It  is  often  necessary 
that  the  bladder  should  be  washed  out,  a  work  which 
will  usually  fall  to  the  physician,  and  one  which  a 
nurse  should  not  undertake  without  special  and  explicit 
directions.  She  should,  however,  know  how  either  to 
wash  out  the  bladder  or  to  assist  in  doing  this  if  called  on 
by  the  doctor.  Usually  a  double  catheter  or  some  par- 
ticularly-designed syringe  is  used  in  this  operation.  It 
may  be  done,  however,  by  attaching  to  an  ordinary 
catheter  a  long  rubber  tube.  The  catheter  is  passed  in 
the  usual  manner,  and  then,  by  means  of  a  funnel  at- 
tached to  the  end  of  the  tube,  warm  water  or  whatever 
liquid  is  directed  can  be  gently  poured  into  the  tube, 
not  more  than  about  two  fluidounces  being  poured  in 
at  one  time.  After  this  has  been  done,  by  simply  low- 
ering the  tube,  the  water  will  be  discharged  from  the 
bladder  and  run  off.  This  process  can  be  repeated  until 
the  discharged  liquid  is  perfectly  clear. 

Bed-sores  are  among  the  most  disagreeable  and 
troublesome  complications  of  chronic  disease  of  the 
nervous  system.  Unless  the  greatest  care  is  taken,  and 
even  sometimes  in  spite  of  close  attention  and  proper  pre- 
cautions, annoying  and  obstinate  sores  will  form  on  those 
parts  of  the  body  subject  to  pressure  or  attrition,  or  to 
the  action  of  irritating  discharges.  The  nurse  should, 
of  course,  be  on  the  watch  to  prevent  their  occurrence ; 
an  ounce  of  prevention  in  such  cases  being  emphatically 
worth  a  pound  of  cure.    Among  the  most  useful  means 


THE  NERVOUS  AND   THE  INSANE.  41 

of  prophylaxis  and  cure,  I  need  only  mention  the  use 
of*  the  water-bed  and  of  air-  aud  water-cushions. 

Small  pillows  may  sometimes  be  used.  When  rub- 
ber air-cushions  are  employed  they  should  be  smoothly 
covered,  and  pins  should  not  be  used  in  the  covers ; 
preferably  they  should  be  sewed  together.  When  a 
water-bed  is  used,  it  is  well  to  put  an  old  blanket  or  a 
cloth  of  some  kind  under  it  to  keep  it  from  sticking. 
The  water  which  is  used  to  fill  it  should  be  at  a  tem- 
perature of  70°  F.,  and  should  be  renewed  every  ten 
days  or  two  weeks,  or  oftener. 

Charcot,  the  distinguished  French  physician,  has 
pointed  out  the  fact  that  occasionally,  in  cases  of  cere 
bral  hemorrhage,  a  few  days  after  the  "  stroke"  an  acutt 
bed-sore  or  eschar  will  form  on  the  buttock  of  the  par- 
alyzed side,  long-continued  pressure  having  nothing  to 
do  with  its  production.  In  rare  instances  the  sore 
occurs  on  the  sound  side.  In  a  case  of  this  kind,  usu- 
ally at  first,  an  erysipelatous  blush  makes  its  appear- 
ance, in  the  centre  of  which  a  vesicle  is  soon  seen,  and 
this  breaking  down,  a  formidabb  sore  rapidly  results. 

Plans  of  treatment  for  bed-sores  without  number  have 
been  tried  and  recommended.  Brown-S^quard  strongly 
advocates  the  use  of  alternate  hot  and  cold  applications. 
For  ten  or  fifteen  minutes  daily,  sponges  soaked  in  hot 
and  cold  water  can  be  thus  employed,  or  ice  bladders 
alternating  with  hot  poultices  may  be  applied.  The 
effect  is  to  stimulate  the  circulation,  and  to  promote  the 
formation  of  granulations.  The  simple  water  dressing, 
the  use  of  carbolized  oil,  and  washes  of  carbolic  acid 
and  potassium  permanganate,  stimulation  with  solution 


42  THE  NURSING  AND   CARE    OF 

of  the  nitrate  of  silver  and  sulphate  of  copper,  packing 
with  iodoform  powder,  the  application  of  charcoal  poul- 
tices and  of  various  ointments,  and  powdering  with 
oxide  of  zinc,  and  other  methods  used  singly,  or  some 
of  them  in  combination,  are  doubtless  all  more  or  less 
familiar  to  nurses  who  have  had  any  experience. 

A  good  plan  to  prevent  the  dfivelopraent  of  bed-sores 
is  to  use  alcohol,  or  the  fluid  extract  of  hamamelis,  as  a 
wash.  It  is  also  important  to  watch  and  turn  the  patient 
from  side  to  side. 

Some  years  ago  I  experimented  in  the  Philadelphia 
Hospital  with  a  method  of  treatment  first  suggested 
by  Spencer  Wells,  of  England.  This  I  consider  very 
valuable.  It  consists  in  taking  a  piece  of  fine  silver 
plate  and  cutting  it  to  the  size  of  the  bed-sore.  A  piece 
of  zinc  of  the  same  size  is  taken,  and  the  two  are  united 
by  a  wire.  The  zinc  plate  is  laid  a  little  above  the  sore, 
and  the  silver  plate  is  laid  on  it,  and  the  two  are  secured 
by  adhesive  strips.  I  have  known  sores,  treated  in  this 
way,  fill  up  with  granulations  in  two  or  three  days. 

A  good  nurse  can  do  much  to  assist  the  physician  in 
the  treatment  of  sleeplessness  from  any  cause.  A  fussy, 
a  talkative,  or  a  thoughtless  nurse  will  be  likely  to  make 
such  a  patient  worse.  The  manner  in  which  the  even- 
ing is  spent  will  often  have  much  to  do  with  the  pro- 
duction of  sleeplessness  or  the  induction  of  sleep.  Even 
when  hypnotics  are  administered  for  the  sake  of  causing 
sleep,  the  way  in  which  this  is  done,  and  the  course 
which  is  pursued  subsequently,  will  have  a  decided  bear- 
ing upon  the  results.    Of  what  avail  will  be  the  drowsy 


THE  NERVOUS  AND    THE  INSANE.  43 

sjrup,  or  the  soothing  draught,  if,  after  its  administra- 
tion, the  nurse  becomes  noisy  and  excites  the  patient? 

In  delirium  tremens,  sleeplessness  and  suicidal  im- 
pulses are  common.  The  pulses  may  be  very  feeble  and 
the  nervous  prostration  and  inability  to  take  food  ex- 
treme. Nourishing  food  must  sometimes  be  given  by 
force,  and  such  patients  must  always  be  closely  watched. 

In  meningitis,  in  tetanus,  in  delirium  tremens,  as 
well  as  in  fevers,  and  in  some  forms  of  insanity  to  be 
hereafter  considered,  the  treatment  of  delirium  will  call 
for  the  intelligent  help  01  the  nurse.  No  matter  to 
what  the  delirium  is  due,  quiet  and  peace  are  always 
essential.  Usually  the  room  should  be  kept  not  only 
quiet  but  to  some  extent  darkened.  Care  should  be 
taken  not  to  unnecessarily  jar  the  bed.  Loud  talking, 
laughing,  or  any  form  of  noise,  should  be  interdicted. 
In  brief,  nothing  should  be  done  to  startle  or  excite. 
In  acute  alcoholic  delirium  the  mental  condition  of  the 
patient  is  sometimes  one  which  requires  extreme  care. 
Terrible  anxiety  with  frightful  hallucinations  of  sight 
and  hearing  are  present.  Sleeplessness  is  continuous. 
The  patient  must  be  vigilantly  watched,  must  be  soothed 
and  comforted,  and  if  necessary  must  be  restrained. 
When  delirium  becomes  so  violent  that  it  is  absolutely 
necessary  to  use  temporary  physical  restraint,  the  greatest 
possible  care  should  be  exercised.  Physical  restraint  is 
indeed  seldom  necessary,  and  should  always  be  avoided 
if  possible.  A  patient  can  sometimes  be  wrapped  in  a 
sheet  or  blanket  for  a  time. 

It  is  not  within  the  scope  of  the  present  chapter  to  go 
into  details  as  to  food  and  its  preparation.    Such  details 


44  THE  NURSING  AND    CARE   OF 

belong  more  properly  to  a  work  on  dietetics.  I  will 
only  say  that  in  the  management  of  nervous  patients 
of  different  classes  attention  to  diet  is  often  of  the  great- 
est importance.  Sometimes,  as  in  the  so-called  *'  rest 
treatment,"  a  special  milk  diet  is  ordered,  or  a  diet  in 
which  the  patient  is  restricted  to  certain  articles  pre- 
pared in  special  ways.  The  orders  given  should  be 
carried  out  explicitly.  If  the  milk  is  to  be  peptonized^ 
it  should  be  exactly  in  the  manner  directed.  If  skim 
milk  is  ordered,  skim  milk  should  be  given ;  and  if 
raw-meat  soup  is  directed  after  having  been  prepared 
in  a  certain  manner,  it  should  be  prepared  in  this  wa}' 
and  in  no  other.  I  wish  to  impress  the  importance  of 
fulfilling  every  detail  of  treatment  with  care  and  exact- 
ness. 

The  management  of  patients  addicted  to  the  opium 
or  other  narcotic  habit  requires  peculiar  qualities  in  a 
nurse.  Firmness  is  here  of  the  utmost  importance,  and 
vigilance  cannot  be  too  great.  The  victims  of  these 
unfortunate  habits  are  weak  in  resolution  beyond  all 
other  sick  people.  It  may  be  laid  down  as  a  general 
rule  that  they  can  never  be  fully  trusted.  The  majority 
of  patients,  says  Kane,  "  express  their  willingness  to  be 
rid  of  their  habit,  and  do  endeavor  up  to  a  certain  point 
to  assist  themselves,  but  at  this  period  will-power,  nat- 
urally weakened,  gives  way,  and  good  resolves  are 
thrown  to  the  wind.  It  is  at  this  time  that  every 
facility  for  full  control  of  the  patient  is  necessary,  for 
without  it  the  sufferer  will  invariably  stop  treatment, 
claiming   that   the   suffering   is  beyond  his  strength, 


THE  NERVOUS  AND    THE  INSANE.  45 

bemoaa  his  sad  fate,  and  return  to  the  old  habit  with 
renewed  force,  exclaiming  with  Coleridge's  son, — 

*  O  woful  impotence  of  weak  resolve.'  " 

Such  patients  must  be  ceaselessly  watched.  They 
must  not  be  allowed  to  come  in  contact  with  servants 
and  otners  through  whom  they  can  buy  the  drug.  Often 
they  may  have  the  narcotic  concealed.  The  nurse  is  in 
these  cases  the  physician's  main-stay ;  if  faithless,  treat- 
ment will  invariably  fail. 

In  the  course  of  the  treatment  of  narcotic  habits  certain 
periods  may  arise  in  which  it  is  important  to  exercise 
the  utmost  care  in  the  management  of  the  patient,  and 
a  nurse  should  be  well  informed  with  reference  to  this 
matter.  In  the  method  of  treatment  advocated  by  the 
German  physician,  Levenstein,  for  example, — that  of 
rapidly  reducing  the  amount  of  the  narcotic  taken, — a 
condition  of  collapse  or  semi-collapse  is  likely  to  come 
on  about  the  time  the  drug  is  entirely  removed,  and 
when  this  occurs  it  is  necessary  that  the  patient  should 
be  closely  watched  and  attended  to  by  the  nurse  as  well 
as  the  physician. 


46  THE  NURSING  AND   CARE  OF 


CHAPTER   II. 

Massage — Movements. 

A  FEW  years  ago  it  was  difficult,  even  in  large  cities, 
to  get  men  or  women  who  were  capable  of  properly  ad- 
ministering massage  to  patients  ;  indeed,  the  number  of 
masseurs  and  masseuses,  skilful  and  unskilful,  was  for 
a  long  time  quite  limited.  The  times  have  changed  in 
this  respect.  Every  large  city  now  contains  many  who 
are,  and  others  who  claim  to  be,  capable  of  giving 
this  treatment.  Often  it  is  simply  a  claim.  Not  a  few 
imagine  that  it  is  only  necessary  to  have  a  little  strength 
and  more  assurance  to  be  able  to  treat  a  patient  by  the 
method  of  massage.  In  consequence  much  evil  results ; 
not  only  to  the  patients,  but  to  the  physician  who  rec- 
ommends the  treatment,  and  to  the  cause  of  massage 
itself.  It  is  not  uncommon  for  nurses  who  have 
managed  perhaps  two  or  three  patients,  and  while 
caring  for  them  have  w^atched  a  skilful  masseur  or 
masseuse  operate,  to  believe  themselves  capable,  with- 
out special  training,  of  undertaking  massage  in  all 
its  forms. 

No  one  should  set  up  as  a  practitioner  of  massage 
without  having  received  special  instruction.  I  have 
known  an  individual  to  undertake  to  administer  mas- 
sage for  pay  after  observing  the  operation  on  one  or  two 
occasions.     Instruction  should  be  received,  and  care 


THE  NERVOUS  AND   THE  INSANE.  47 

should  be  taken  that  it  is  of  the  proper  kind.  A  nurse 
to-day  cannot  be  a  masseur  or  masseuse  to-morrow 
simply  by  thinking  over  the  matter.  Both  teaching 
and  preliminary  practice  are  requisite  to  make  a  good 
operator.  The  amount  of  time  required  thoroughly  to 
learn  the  art  depends  upon  the  intelligence,  tact,  and 
manual  skill  of  the  individual  as  well  as  upon  the  kind 
of  teaching  and  the  amount  of  practice. 

It  is  not  absolutely  necessary  that  masseurs  should 
have  a  comprehensive  knowledge  of  anatomy  and 
physiology,  but  they  should  know  something  of  these 
branches  of  medical  science;  they  should  know  the 
names,  positions,  and  modes  of  action  of  the  principal 
muscles  and  groups  of  muscles  of  the  body ;  they 
should  know  something  of  the  size  and  shape  or  con- 
tour of  these  muscles  in  order  that  they  may  be  better 
able  to  isolate  and  treat  them ;  for  quick  reference  some 
idea  of  the  arrangement  and  distribution  of  the  muscles 
may  be  obtained  from  illustrations  7,  8,  9,  10,  11  and 
12.  They  should  know  something  of  the  skin  and  its 
functions  and  powers. 

In  my  own  practice,  both  hospital  and  private, 
I  have  made  it  a  point  to  study  the  methods  of 
operators,  and  I  find  that  these  differ  very  much.  In 
Philadelphia,  the  majority  of  those  who  attempt  mas- 
sage have  methods  which  are,  in  some  respects,  wrong, 
although  we  have  here  a  respectable  minority  of  skilful 
operators.  I  have  not  only  watched  the  procedure 
myself,  whenever  opportunity  offered,  but  have  also 
questioned  my  patients  as  to  their  own  feelings  and 
observations.     To  a  majority  of  nervous  patients,  maS" 


48  THE  NURSING  AND   CARE  OF 

sage  is  pleasant ;  some  care  but  little  for  it ;  to  a  few  it 
seems  to  be  absolutely  intolerable.  ^Hien,  however,  a 
patient  complains  that  she  does  not  like  or  cannot  en- 
iure  the  procedure,  I  always  make  it  a  point  to  observe 
the  method  pursued.  I  have  had  patients  who  were 
rendered  more  nervous  by  massage  administered 
by  one,  speak  of  it  as  almost  a  luxury  when  they 
have  received  the  treatment  from  the  hands  of  another. 
One  of  my  patients,  an  intelligent  lady,  had  in  succes- 
sion, although  not  by  my  orders,  five  different  mas- 
seuses. Her  rather  amusing  criticisms  upon  these 
individuals  serve  to  point  out  some  of  the  things  to  be 
avoided.  She  said  that  the  first  teased  and  tantalized 
her ;  the  second  wrung  and  twisted  her ;  the  third 
mauled  and  bruised  her ;  the  fourth  was  too  dainty ; 
and  the  fifth  almost  talked  her  to  death.  The  patient 
may  have  been  a  little  hard  to  please,  but  in  the  main 
her  criticisms  were  just. 

MurrelP  says  that  the  word  massage  is  derived,  ac- 
cording to  some  authorities,  from  a  Greek  word  mean- 
ing to  "  rub,'^  while  others  refer  it  to  the  Arabic  word 
mass,  to  press  softly.  Dr.  Benjamin  Lee^  says  that  it 
comes  to  us  from  the  Greek  through  the  French,  and 
means  simply  "kneading,"  the  idea  to  be  conveyed 
being  that  the  operator  works  the  flesh  as  the  baker 
works  his  dough.  He  holds  correctly  that  it  is  better  to 
use  the  French  word  than  to  attempt  to  translate  it  into 


* "  Massage  as  a  Mode  of  Treatment," 

' "  Tracts  on  Massage."     Translated  from  the  German  of  Beib- 
mayr,  with  notes,  Philadelphia,  1885. 


THE  NERVOUS  AND   THE  INSANE.  49 

English,  because  the  English  equivalent  is  used  to  de- 
.  scribe  one  of  the  particular  modes  of  massage,  and  also 
because  the  former  has  now  a  well-established  position 
and  definite  signification  in  scientific  medical  literature 
all  over  the  world.  The  same  authority  defines  mas- 
sage as  a  communication  of  motion  to  the  tissues  of  the 
living  human  body  from  an  external  source  for  thera- 
peutic purposes ;  but  this  definition  does  not  define  the 
term  as  it  is  commonly  used, — that  is,  under  it  might 
be  included  Swedish  movements  and  motion  commu- 
nicated by  means  of  steam,  electricity,  or  special  me- 
chanical agency.  The  latter  forms  of  massage  are 
sometimes  spoken  of  as  mediate, — that  is,  they  are 
motions  or  movements  communicated  to  the  body 
through  some  contrivance  or  machine.  It  is  to  what 
is  sometimes  called  immediate  massage  that  the  term  is 
commonly  restricted,  and  it  is  with  reference  to  this 
form  that  my  remarks  in  this  connection  apply.  Mas- 
sage, then,  in  the  sense  in  which  I  here  employ  the 
term,  is  the  manipulation  by  a  definite  process  of  the 
tissues  and  organs  of  the  human  body  by  a  living 
operator,  for  the  purpose  of  promoting  health  or  of 
relieving  or  curing  disease. 

The  subject  has  been  unnecessarily  confused  and 
complicated  by  the  multiplications  of  terms  describing 
so-called  methods  of  massage ;  thus,  Estrader^,  accord- 
ing to  Lee,  speaks  of  such  a  variety  of  procedures  as 
stroking,  friction,  kneading,  sawing,  pulling,  pinching, 
malaxation,  percussion,  chopping,  clapping,  pointed 
vibrations,  and  deep  vibrations.  These  terms  really 
represent  only  a  few  essential  methods  of  procedure. 

4 


50  'J^SE  NURSING  AND   CARE  OF 

The  best  authorities,  as  Mezger,  Berghman  and  Helle- 
day,  Lee,  Murrell,  Jacoby,  and  others,  describe  four 
essential  methods  of  procedure,  namely,  (1)  stroking,  or 
effleurage;  (2)  friction,  massage  CL  friction ;  (3)  knead- 
ing, or  petrissage;  and  (4)  percussion,  or  tapotement 
Understanding  these  four  methods  practically,  it  will 
be  found  that  the  other  so-called  varieties  are  simply 
modifications  of  these,  or  are  not  strictly  forms  of  mas- 
sage, but  come  more  properly  under  the  head  of  exercise 
or  movements. 

My  special  purpose  in  this  chapter  is  to  give  a 
few  hints  and  suggestions  as  to  proper  and  improper 
methods  of  performing  massage.  For  details  and  de- 
scriptions of  the  procedure,  the  writings  of  Lee,  Mur- 
rell, Jacoby,  and  others  can  be  consulted.  I  will, 
however,  for  the  sake  of  a  clear  understanding  of  what 
is  said,  quote  the  essential  portions  of  the  descriptions 
by  Jacoby^  of  the  principal  kinds  of  massage. 

"  Stroking  is  nothing  more  than  a  very  light  centrip- 
etally-propelled  pressure.  It  is  executed  in  the  fol- 
lowing manner :  The  volar  surface  of  the  ends  of  the 
fingers,  or  of  the  entire  hand,  having  been  applied  to 
the  part  to  be  massaged,  at  a  point  situated  more 
peripherally  than  the  affected  portion,  is  then  pushed 
centripetal  ly  forward  and  a  short  distance  beyond  that 
part.  When  this  hand  has  reached  its  destination,  the 
other  hand  is  placed  at  the  starting-point  and  the  same 
movement  executed.     Meanwhile   the   first  hand   has 


1  *' Journal  of  Nervous  and  Mental  Disease,"  vol.  xii.,  No.  4, 
October,  1885. 


THE  NERVOUS  AND   THE  INSANE.  51 

been  brought  back,  so  that  by  the  time  the  second  one 
'has  fulfilled  its  purpose  it  is  ready  to  begin  again. 
This  is  then  repeated  with  regularity.  The  time  to  be 
devoted  to  each  stroke  will  vary  very  much,  the  strokes 
also  following  with  more  or  less  rapidity.  The  amount 
of  pressure  to  be  applied  is  not  to  exceed  that  of  the 
dead  weight  of  the  hand.  Effleurage  of  the  extremities 
may  also  be  executed  in  such  a  manner  that  the  thumb 
and  first  finger  are  widely  separated  like  a  Y,  and  the 
extremity  grasped  between  them.  Mosengeil  advocates 
the  use  of  a  certain  amount  of  pressure  in  this  ma- 
noeuvre ;  in  fact,  he  recommends  varying  the  pressure 
from  moment  to  moment,  so  that  it  becomes  undulating 
in  form." 

"  Massage  h  friction,  or  rubbing,  is  a  forcible  press- 
ure with  a  concomitant  motion  of  the  hand  forward. 
This  manipulation  may  be  executed  in  various  manners. 
The  points  of  the  fingers  having  been  applied  to  the 
affected  part,  pressure  is  exercised,  and  they  are  moved 
in  large  or  small  circles,  or  simply  to  and  fro,  the  press- 
ure being  maintained.  For  this  purpose  the  ends  of 
one  or  more  fingers  may  be  employed.  If  a  particu- 
larly great  amount  of  force  is  desired,  the  first  phalanx 
of  the  thumb  of  the  left  hand  may  be  applied  to  the 
spot,  and  pressure  exercised  upon  its  dorsal  surface  with 
the  thumb  of  the  other  hand,  the  rubbing  then  being 
executed  with  both  together.  By  this  means  we  are 
enabled  to  act  upon  deeper-lying  structure.  Rubbing 
and  stroking  ought  to  be  combined  in  such  a  manner 
that  the  operator  simultaneously  executes  the  one  with 
his  right  hand  and  the  other  with  his  left." 


52  THE  NURSING  AND   CARE  OF 

"  Petrissage,  a  kneading  in  the  true  sense  of  the 
word,  may  be  applied  wheresoever  soft,  graspable  tis- 
sues are  present,  and  very  intense  effects  may  be  at- 
tained by  it.  The  part  to  be  acted  upon,  generally  a 
muscle,  is  grasped  between  the  thumb  and  index  finger, 
or  between  the  thumb  on  the  one  side  and  the  four  fin- 
gers upon  the  other.  It  is  then  isolated  as  much  as 
possible  and  lifted  out  of  its  bed,  at  the  same  time 
pressure  being  exerted  upon  a  certain  part.  Then  those 
parts  more  centrally  located  are  taken,  until  the  entire 
muscle  has  been  acted  upon.  For  this  purpose  either 
the  points  of  the  fingers  or  the  pulps  of  the  terminal 
phalanges  may  be  used.  If  the  points  of  the  fingers 
are  employed,  the  procedure  is  certainly  rendered  more 
energetic,  but  at  the  same  time  more  fatiguing  for  the 
operator. 

"Petrissage  may  also  be  rendered  more  energetic, 
when  acting  upon  large  parts,  by  using  both  hands. 

"  Tapotement  is  simply  percussion  of  the  affected 
part,  either  with  the  palm  of  the  hand,  the  fist,  the 
curved  finger,  a  percussion  hammer,  or  other  instrument 
specially  adapted  for  the  purpose.  Percussion  without 
instruments  is,  as  a  rule,  performed  with  the  points  of 
the  fingers,  these  being  semiflexed,  and  the  movements 
of  the  percussing  hand  taking  place  at  the  wrist.  It  is 
this  form  which  is  most  applicable  over  superficial 
nerves.  When  it  is  deemed  desirable  to  act  more  en- 
ergetically upon  deeper-lying  structures,  generally  large 
muscular  groups,  the  wrist-joint  must  be  stiffened,  the 
fingers  held  firmly  extended,  and  motion  allowed  to 
take  place  at  the  elbow  and  partly  at  the  shoulder-joint, 


THE  NERVOUS  AND   THE  INSANE.  53 

the  hand  of  the  operator  thus  meeting  the  body  of  the 
'  patient  at  right  angles." 

The  terms  which  are  used  to  designate  those  who 
follow  massage  as  a  business,  and  also  the  methods  and 
processes  of  massage,  are  somewhat  awkward  for  Eng- 
lish-speaking people,  more  particularly  for  nurses  and 
operators  who  have  not,  as  they  cannot  be  expected  to 
have,  a  French  as  well  as  an  English  education.  The 
proper  term  for  a  male  operator  is  massmr,  for  a  female, 
masseuse^  the  plurals  being  masseurs  and  masseuses. 
The  verb  which  expresses  the  performance  of  the  pro- 
cedure is  masser.  It  is  therefore  proper  to  speak  of  a 
patient  as  being  mass^ed,  or  of  mass^eing  a  patient.  I 
would  not  advise  the  use  either  of  massageing  or  of 
"  massacreing,"  although  the  former  is  sometimes  used 
by  good  authority.  The  latter  is  certainly  expressive 
in  describing  the  violent  performances  of  some  of  the 
untrained  exponents  of  the  art.  It  is  common  to  speak 
of  the  process  as  "  rubbing,"  "  kneading,"  or  "  manip- 
ulating," and  perhaps  the  use  of  one  or  the  other  of 
these  expressions  cannot  always  be  avoided ;  but  as  they 
convey  double  meanings,  or  do  not  really  express  in 
English  what  is  wished  to  be  said,  it  is  better  to  use  the 
French  terms  until  some  more  exact  English  equivalent 
is  suggested. 

As  in  making  electrical  applications,  so  in  using 
massage,  attention  should  be  paid  to  the  position  of  the 
muscles  and  of  the  limbs.  The  muscles  should  not  be 
tense ;  the  limbs  and  trunk  should  be  so  placed,  or  so 
supported,  as  to  be  in  a  position  of  relaxation  :  usually 
this  can  be  accomplished  by  having  the  limbs,  as  recom- 


54  THE  NURSING  AND   CARE  OF 

mended  by  Graliam,  midway  between  flexion  and  ex- 
tension. A  muscle  which  is  tense  and  contracted  cannot 
be  thoroughly  manipulated. 

A  certain  knack  or  tact  is  soon  acquired  by  a  good 
masseur  or  masseuse.  In  most  cases  wrist  and  hand 
movement  should  be  employed.  Just  as  it  is  important 
at  the  start  for  the  young  physician  to  obtain  what  is 
called  the  wrist  movement  in  percussing  patients,  so  it 
is  essential  that  any  one  attempting  massage  should 
understand  these  wrist  movements.  Patients  should 
not  be  mauled  and  twisted  by  movements  which  call 
into  play  the  muscles  of  the  arms  and  trunk,  when  the 
whole  procedure  can  be  better  accomplished  by  the  fore- 
arms and  hands. 

Wherever  it  is  possible,  the  operator  should  learn  to 
use  both  hands  at  once.  If  the  left  hand,  as  in  so 
many  cases,  is  comparatively  useless,  efforts  should  be 
made  to  train  it  especially,  using  it  in  preference  to  the 
other  hand  until  the  two  become  equally  skilful.  To 
be  ambidextrous  or  either-handed,  is  a  great  advantage 
in  a  masseur. 

Should  the  massage  be  dry,  or  should  grease  or  lini- 
ments of  some  kind  be  used  ?  Differences  of  opinion 
about  this  practical  matter  prevail  among  those  who 
have  taught  and  written  upon  the  subject.  Mitchell, 
for  example,  advises,  or  at  least  permits,  in  some  cases, 
the  use  of  cocoa-oil  or  vaseline,  but  says  that  these 
make  the  work  less  efficient  and  more  difficult.  He 
does  not  order  them  unless  it  is  considered  advisable  to 
rub  into  the  system  some  oleaginous  material.  Busch 
and  some  other  writers  strongly  recommend  the  em- 


THE  NERVOUS  AND   THE  INSANE.  56 

ployment  of  oil,  liniments,  or  ointments ;  Murrell  as 
'sti*6ngly  favors  the  dry  method,  saying  that  the  less 
ointment  one  uses  the  better,  and  that  vaseline  is 
never  admissible.  The  only,  or  almost  the  only,  excep- 
tion he  makes  is  when  the  patient  suffers  from  some 
form  of  specific  disease,  when  the  operator  should  use 
an  antiseptic  preparation,  carbolic  acid  or  oil  of  cloves 
and  lard,  for  example,  for  his  own  safety  and  protection. 
My  own  view  is  that,  as  a  rule,  nothing  in  the  form  of 
oil,  grease,  or  liniment  should  be  employed.  A  skilful 
operator  will  usually  do  better  without  than  with  any- 
thing of  this  kind. 

Some  attention  must  be  paid  to  the  direction  in  which 
massage  is  carried  out, — that  is,  whether  from  the 
periphery  towards  the  centre  of  the  body,  or  from  the 
centre  towards  the  periphery.  As  a  rule,  the  operation 
should  be  "  from  the  extremities  to  the  trunk,  from  the 
insertion  to  the  origin  of  the  muscles,  and  in  the  di- 
rection of  the  returning  currents  of  the  circulation^' 
(Graham).  The  rule,  however,  is  not  invariable,  but  the 
masseur  is  not  to  be  supposed  to  have  sufficient  knowl- 
edge of  the  subject  to  decide.  The  physician  should 
decide;  but  when  no  special  orders  are  given,  it  is 
proper  to  begin  at  the  extremities — at  the  fingers  or 
toes — and  proceed  up  the  limbs,  finishing  with  the 
muscles  of  the  back,  chest,  and  abdomen. 

A  peculiar  twisting  or  wringing  movement  used  by 
some  operators  should  be  especially  avoided.  In  ma- 
nipulating the  fingers,  for  instance,  instead  of  support- 
ing the  under  surface  of  the  finger  and  mass^eing  by 
causing  the  ball  of  the  thumb  to  adhere  to  the  muscle 


56  THE  NURSING  AND   CARE  OF 

by  downward  pressure  and  then  gently  rotating,  a  twist- 
ing spiral  movement  is  performed  around  the  entire 
finger.  In  the  same  way  the  thumb  or  the  hand  is 
made  to  perform  twisting  or  pulling  or  separating  move- 
ments across  the  larger  muscles,  instead  of  pinching, 
kneading,  or  rolling  them  skilfully.  Sometimes  the 
process  is  simply  a  form  of  irregular  friction  of  the 
skin  instead  of  being  true  massage. 

It  is  of  vital  importance  that  those  who  follow  mas- 
sage as  a  business  should  keep  in  good  physical  condi- 
tion. If  the  number  of  patients  treated  is  small,  a 
little  extra  exercise  may  be  taken.  On  the  other  hand, 
too  many  patients  should  not  be  undertaken  in  a  single 
day.  Probably  five  or  six  patients  are  as  many  as 
can  be  done  justice  to  by  an  operator  in  good  physical 
condition  ;  but,  of  course,  the  exact  number  will  depend 
in  great  measure  upon  individual  skill  and  endurance. 
If  too  many  patients  are  treated,  those  who  come  last 
will  be  likely  to  be  slighted,  and  hardly  anything  will 
prove  more  injurious  to  the  business  of  the  operator 
than  this.  My  experience  is  that  patients  pay  close 
attention  to  the  directions  of  the  physician  as  to  the 
length  of  time  which  is  to  be  devoted  each  day  to  the 
procedure.  In  this,  as  in  so  many  other  matters,  pa- 
tients wish  to  get  the  worth  of  their  money.  They 
soon  learn  whether  some  part  of  the  body  is  not  re- 
ceiving proper  attention. 

It  requires  considerable  strength  and  vigor  to  be  a 
good  masseur  or  masseuse ;  but  better  even  than  strength 
and  vi2:or  is  the  abilitv  to  use  what  streno^:h  the  indi- 
\ddual  possesses  to  the  best  advantage ;  in  other  words, 


THE  NERVOUS  AND   THE  INSANE.  57 

skill.  The  mistake  is  made  by  some  operators  of  sup- 
posing that  vigorous  or  even  violent  treatment  is  re- 
quired. I  have  heard  the  practitioners  of  massage  of 
a  certain  city,  which  I  will  not  name,  spoken  of  as 
greasers  and  bruisers,  and  while  I  do  not  think  this  is 
deserved  by  them  as  a  class,  the  practice  of  a  few  gave 
some  reason  for  the  derision.  Patients  should  not  be 
roughly  handled.  In  some  cases  after  the  first  few 
treatments,  if  the  individual  has  had  a  delicate  skin  or 
some  peculiar  state  of  the  circulation,  some  marks  and 
bruises  may  be  left  upon  the  body,  even  when  the  oper- 
ation has  been  performed  skilfully  and  not  improperly ; 
but  patients  should  not  appear  after  such  an  operation 
covered  with  bruises  and  blotches  as  if  they  had  fallen 
down  a  precipice  or  had  been  to  Donny brook  Fair.  I 
have  known  patients  comparatively  strong  complain 
bitterly  of  the  severity  of  the  treatment  to  which  they 
have  been  subjected. 

On  the  other  hand,  it  is  possible  for  the  treatment 
which  is  given  to  be  too  mild,  or  to  be  slighting  in 
character.  A  patient  should  always  be  thoroughly 
treated,  should  be  gone  over  systematically.  One  part 
of  the  body  should  not  be  treated  with  vigor  and  an 
other  slighted.  An  operator  who  is  not  very  strong,  or 
who  attempts  to  do  too  much  work  in  one  day,  will 
sometimes  start  out  vigorously  enough,  but  before  get- 
ting through  will  become  fatigued,  and  in  consequence 
the  part  of  the  body  which  receives  attention  last  will 
also  receive  it  least.  The  operator  should  so  gauge  time 
and  strength  as  to  be  able  to  carry  out  the  entire  treat- 
menl   uniformly.     Treatment  should,  if  anything,  end 


58  THE  NURSING  AND   CARE  OF 

with  more  vigorous  movements  than  are  employed  at 
the  start. 

1  may  be  pardoned  also  for  making  a  few  remarks  as 
to  the  mental  requirements  of  masseurs.  They  should 
be  discreet  and  judicious,  and  should  have  that  persona] 
quality  which  is  best  expressed  by  the  term  "  common 
sense."  Inquisitiveness  is  to  be  avoided.  They,  like 
the  doctor,  may  be  called  upon  sometimes  to  penetrate 
the  privacy  of  families,  and  they  should  first,  before 
all,  learn  to  mind  their  own  business.  Where  more 
than  one  patient  is  in  a  house  or  hospital,  it  is  well  not 
to  pry  too  much  into  matters  relating  to  other  patients 
than  the  one  being  treated.  Talking  too  much  should 
be  avoided.  Some  practitioners  of  massage  are  as  gar- 
rulous as  the  traditional  barber,  and  are  as  much  of  a 
nuisance  to  their  victims.  It  is  not  necessary,  nor  to 
be  advised,  that  they  should  be  taciturn  or  morose  in 
the  presence  of  patients.  A  little  pleasant  talk  will  do 
no  Harm,  but  they  should  avoid  undue  talkativeness ; 
they  should  particularly  avoid  gossiping  and  boasting 
of  their  own  powers.  They  should  not  set  themselves 
up  as  "  magnetic  healers"  or  "  professors,"  being  partic- 
ularly careful  not  to  impress  either  doctor  or  patient  as 
to  the  amount  of  electricity  they  can  convey  by  their 
manipulations. 

The  masseur  should  refrain  from  talking  much 
in  the  evening,  so  as  not  to  charm  away  sleep. 
The  lights  should  be  turned  away  from  the  patient's 
eyes  when  the  seance  is  in  the  evening. 

The  patient  should  be  in  a  well- ventilated  room,  say 
of  70°.     The  chest  should  be  elevated  somewhat,  so  as 


THE  NERVOUS  AND   THE  INSANE.  59 

to-promote  free  and  easy  respiration.  Each  limb  should 
be  covered  after  being  treated,  and  the  masseur  should 
not  unnecessarily  expose  any  part  of  the  patient.  The 
masseur  or  masseuse  should  refrain  from  harassing  the 
patient's  mind  by  talking  of  his  disease.  The  physician 
should  in  some  cases  inform  the  operator  as  to  the  pur- 
pose for  which  the  massage  is  applied,  as  this  will  give 
the  masseur  more  confidence  and  make  more  certain 
as  to  the  thorough  performance  of  his  work. 

The  treatment  should  be  commenced  very  gently, 
gradually  increasing  in  strength  as  the  patient  becomes 
more  able  to  bear  it.  Care  should  be  taken  not  to 
overdo  the  treatment  on  the  first  attempt.  The  mas- 
seur should  exercise  his  judgment  as  to  the  amount  of 
vitality  and  physical  strength  possessed  by  the  patient, 
and  upon  this  in  part  the  treatment  should  be  based. 

During  the  last  few  years  we  have  been  recognizing 
a  condition  in  which  massage  has  a  distinctive  use. 
This  disorder  is  known  as  "  fibrositis.  '^  A  number  of 
articles  have  been  published  upon  tliis  subject.^     The 

lYawger,  N.  S.  "Indurative  Headache  (Schwielenkopf- 
schmerz)  with.  Report  of  Three  Cases  "  :  Journal  American 
Medical  Association,  April  24,  1909,  p.  1316. 

"Chronic  'Rheumatic'  Myositis  (Muskelschwielen),  with 
Cases  Showing  Some  Common  Errors  in  Diagnosis":  The  Lan- 
cet, London,  July  31,  1909,  p.  292. 

"  Sciatica  as  Caused  by  '  Rheumatic '  Myositis  in  the  Gluteal 
Region  ;  Its  Diagnosis  and  Treatment"  :  University  of  Pennsyl- 
vania Medical  Bulletin,  Sept.  10,  1910,  p.  321. 

"  '  Fibrositis '  as  a  Cause  of  Chronic  Hypertrophic  Spondylitis, 
and  Possibly  with  a  Heretofore  Undescribed  Sign  in  Intestinal 
Auto-intoxication"  :  Boston  Medical  and  Surgical  Journal,  July 
15,  1911,  p.  843. 


60  THE  NURSING  AND   CARE  OF 

commonest  example  of  this  condition  is  the  stiffness 
and  soreness  that  some  persons  experience  after  expos- 
ure to  a  draft.  It  is  familiarly  known  as  muscular 
rheumatism.  Another  frequent  cause  is  some  poison- 
ous substance  formed  within  the  body  of  the  patient 
and  carried  about  by  the  circulation  until  it  finds  lodg- 
ment at  some  point  where  it  sets  up  irritation,  with  the 
result  that  an  area  of  fibrositis  develops.  Strictly 
speaking,  the  muscular  tissue  is  not  the  seat  of  the  dis- 
ease, it  being  mostly  confined  to  the  strands  of  white 
fibrous  counective  tissue  and  the  fascia  that  run  among 
the  muscles  and  muscle  fibres ;  hence  the  name,  fibro- 
sitis. Since  the  fibrous  connective  tissue  is  found  in 
most  parts  of  the  body,  it  is  not  surprising  that  fibro- 
sitis may  develop  almost  anywhere.  The  particular 
disorders  which  it  most  frequently  leads  to  are  head- 
ache, backache,  lumbago,  neuralgia,  sciatica,  and  painful 
feet.  Massage  should  be  supplemented  by  exercises  to 
bring  into  play  the  muscles  which  are  the  seat  of 
fibrositis. 

Movements,  in  the  medical  sense,  are  certain  motions 
and  operations  performed  for  the  purpose  of  helping 
the  diseased  human  body.  They  are,  as  Taylor  ex- 
presses it,  motions  of  specific  kinds,  having  specific 
effects,  practised  for  specific  purposes,  and  intended  to 
secure  definite  results.  Complicated  apparatus  is  not 
required  to  carry  out  the  movement  treatment  and  my 
remarks  will  have  reference  chiefly  to  procedures  which 
do  not  call  for  any  special  apparatus. 

By  writers  and  teachers  various  divisions  and  sub- 
divisions of  movements  have  been  laid  down.    Efforts 


THE  NERVOUS  AND    THE  INSANE.  61 

have  been  made  by  Ling  and  others  to  designate  and 
classify  both  positions  and  movements ;  in  other  words, 
to  establish  a  terminology  for  the  movement  cure.  It 
is  not  my  purpose,  however,  to  go  into  this  branch  of 
the  subject  at  present. 

Movements  are  sometimes  spoken  of  as  active  and 
passive,  or  as  single  and  duplicated.  Active  move- 
ments are  those  more  or  less  under  the  control  of  the 
individual  making  or  taking  part  in  them,  and  they  are 
performed  by  him  under  the  advice  or  direction,  and 
sometimes  with  the  assistance,  of  another.  They  pro- 
ceed from  within ;  they  are  willed.  Passive  movements 
come  from  without;  they  are  performed  on  the  patient, 
and  independently  of  his  will.  He  is  subjected  to 
pushings  and  pul lings,  to  flexions  and  extensions,  to 
swingings  and  rotations,  which  he  can  neither  help  nor 
hinder.  The  same  movement  may  be  active  or  passive 
according  to  circumstances.  A  man's  biceps  may  be 
exercised  through  his  will,  against  his  will,  or  without 
reference  to  his  will.  Speaking  medically,  single  move- 
ments are  those  not  executed  by  the  physician  or 
attendant,  but  by  the  patient ;  they  are,  of  cou  rse,  active. 
Duplicated  movements  require  more  than  one  for  their 
performance.  Duplicated  active  movements  are  those 
to  which  I  most  commonly  resort  in  the  treatment  of 
nervous  disorders.  In  these  the  element  of  resistance 
plays  an  important  part.  The  operator,  with  carefully- 
considered  exertion,  performs  a  movement  which  the 
patient  is  enjoined  to  resist;  or  the  latter  undertakes  a 
certain  motion  or  series  of  motions  which  the  former, 


62  THE  NURSING  AND   CARE  OF 

with  measured  force,  resists.  Skill  and  experience 
are  here  of  great  value,  in  order  that  both  direct 
effort  and  resistance  should  be  carefully  regulated  and 
properly  modified  to  suit  all  the  requirements  of  the 
case.  By  changing  the  position  of  the  patient,  or  the 
manner  of  operating  on  him,  from  time  to  time,  any 
muscle  or  groups  of  muscles  may  be  brought  into 
play.  It  is  wonderful  with  what  ease  even  some  of 
the  smallest  muscles  can  be  exercised  by  an  expert  ma- 
nipulator. 

To  impress  what  is  meant  by  duplicated  active  move- 
ments, I  will  illustrate  them  by  supposing  two  cases, 
one,  a  case  of  partial  paralysis  of  the  muscles  of 
one  arm,  the  other  a  patient  with  hysterical  paraplegia. 
In  these  cases  muscular  exertion  can,  to  some  extent, 
be  called  forth,  the  paralysis  not  being  absolute.  Sup- 
pose it  is  desired  to  bring  into  activity  the  biceps  and 
brachialis  anticus,  the  muscles  particularly  engaged  in 
flexing  the  forearm.  The  arm  being  extended,  with 
the  palm  of  the  hand  upward,  the  manipulator  takes 
hold  about  the  wrist  and  directs  the  patient  to  draw  the 
hand  toward  the  shoulder.  As  the  latter  performs  this 
movement,  the  former  carefully  resists,  gradually,  how- 
ever, allowing  the  hand  to  reach  the  shoulder,  where 
the  patient  tries  to  keep  it,  while  the  operator  now 
slowly  brings  the  arm  again  to  its  extended  position. 

To  act  upon  the  muscles  of  the  trunk,  the  patient  is 
seated  upon  a  stool  of  the  proper  height,  without  back 
or  arms,  and  is  directed  or  caused  to  bend  forward  or 
backward  or  sidewise,  or  to  semi-rotate  the  body,  or 
to  perform  any  other  desirable  movement,  the  operator 


THE  NERVOUS  AND    THE  INSANE.  63 

antagonizing  the  patient  and  the  patient  the  operator. 
The  arms  may  or  may  not  be  made  to  take  part  in  these 
movements,  being,  in  the  former  case,  elevated,  flexed, 
extended,  etc.,  in  unison  with  the  movements  of  the 
trunk.  If  it  is  wished  to  exercise  any  or  all  of  the  mus- 
cles of  the  lower  limbs,  the  process  is  obvious.  Begin- 
ning with  the  toes,  these  being  flexed,  while  the  patient 
endeavors  to  extend  them  the  operator  resists  his  efforts, 
or  the  procedure  may  be  reversed,  the  patient  offering 
the  resistance.  Similar  methods  are  adopted  for  calling 
into  play  and  developing  the  extensors,  abductors,  ad- 
ductors, etc.,  of  both  feet  and  legs. 

These  duplicated  active  movements  are  designed  to 
call  out  the  latent  power  in  the  muscles  of  the  indi- 
vidual. They  are  called  duplicated  active  movements 
because  the  operator  and  the  patient  take  part  in  them, 
and  the  important  practical  point  is  to  see  that  both  do 
take  part.  Great  skill  is  acquired  by  some  operators 
in  this  matter.  The  various  movements  of  the  trunk 
and  limbs  should  be  carefully  studied,  and  the  masseur 
should  learn  by  practice  the  neatest  and  least  awkward 
method  of  opposing  the  patient^s  movements  or  causing 
the  patient  to  resist  the  force  applied.  As  in  massage, 
observation  of  two  manipulators  will  reveal  the  greatest 
difference  in  this  respect :  one  will  be  quick,  easy, 
graceful,  and  encouraging ;  the  other  will  be  slow,  stiff, 
awkward,  and  disheartening.  The  force  which  is  used 
should  be  carefully  graduated  to  the  strength  and  par- 
ticular conditions  of  the  patient.  The  movement  which 
it  is  desired  to  bring  out  and  improve  should  not  be  too 
forcibly  resisted.     Patients  can  be  helped  on  to  a  cure 


64  THE  NURSING  AND   CARE   OF 

much  more  rapidly  by  carefully  coaxing  out  their  latent 
energies. 

Deep  breathings  can  often  be  combined  advanta- 
geously with  various  forms  of  active  movements.  A 
favorite  method  of  treatment  with  the  writer,  and  one 
which  often  needs  to  be  supervised  by  the  nurse,  is 
exercising  the  patient  with  light  dumb-bells  or  with 
pulley-weights,  accompanying  the  movements  with 
deep  breathings.  The  exercise  should  be  very  moder- 
ate at  first,  but  should  be  gradually  increased,  and  it  is 
always  best  to  give  the  treatment  in  a  well-ventilated 
room. 


THE  NERVOUS  AND   THE  INSANE.  65 


CHAPTER    III. 

Hydrotherapy. 

In  the  care  and  treatment  of  nervous  and  insane 
patients,  bathing,  either  general  or  local,  is  frequently 
employed.  In  text-books  on  general  nursing  and  spe- 
cial works  on  hydro-therapeutics  details  of  the  different 
forms  of  baths  and  special  procedures  will  be  found. 
I  may,  however,  say  a  few  words  about  certain 
forms  of  bathing.  In  the  treatment  by  rest,  seclusion, 
massage,  and  electricity  it  is  nearly  always  advisable 
that  a  sponge-bath  should  be  given  early  every  morning. 
It  should  be  done  quickly  and  carefully.  The  spong- 
ing should  be  downward ;  the  addition  of  a  little  alcohol 
to  the  water  will  sometimes  make  it  pleasanter  and  more 
desirable  where  it  is  intended  to  get  a  cooling  effect. 
The  sponging  should  be  cold  or  tepid,  according  to  the 
directions  of  the  physician  ;  usually  tepid  sponging  is 
to  be  preferred,  particularly  in  the  early  period  of  treat- 
ment. It  is  a  well-known  rule  founded  on  physiolog- 
ical principles  that  baths  should  not  be  taken  immedi- 
ately after  meals.  The  sponge-bath,  however,  may  be 
taken  after  a  cup  of  milk,  cocoa,  or  coffee  in  the  morn- 
ing, or  it  may  be  given  as  other  baths  are  administered 
between  meals  or  at  bedtime.  Even  the  sponge-bath 
should  not  be  given  when  the  stomach  is  fiill  of  food. 

Dr.  Mitchell  says  that  for  some  reason  the  act  of 

6 


66  TBE  NURSING  AND  CARE  OF 

bathing,  or  even  being  bathed,  is  mysteriously  fatiguing 
to  certain  invalids,  and  if  so  the  general  sponging 
should  be  done  for  a  time  but  thrice  a  week.  With 
reference  to  the  matter  of  the  temperature  of  the  water 
to  be  used,  either  sponge  or  other  bathing,  the  nurse 
should  be  observant,  and  should  report  the  effects  to  the 
physician  so  that  he  may  be  guided  in  his  direction. 

Other  useful  methods  are  the  hot  and  cold  pack,  the 
salt  rub,  and  the  prolonged  warm  immersion  bath. 

In  the  hot  pack  the  bed  is  protected  by  a  rubber 
sheet  or  blanket  folded  several  times.  Blankets  are 
used  and  are  wrung  out  of  water  several  degrees  higher 
than  is  desired  for  the  pack.  One  blanket  is  placed 
under  the  patient  and  another  over.  Over  the  latter 
are  spread  heavy  blankets  or  quilts.  A  cold  compress 
is  placed  on  the  head. 

For  the  cold  pack  sheets  are  used  and  the  arms  may 
be  wrapped  in  towels.  If  the  sheet  becomes  too  warm, 
cold  water  may  be  sprinkled  over  it.  The  average  time 
for  such  a  pack  is  from  twenty  to  forty  minutes. 

In  administering  these  packs,  the  pulse  must  be  care- 
fully watched,  and  any  sign  of  weakness  is  cause  for 
immediate  interruption  or  cessation  of  the  treatment. 
The  Bait  rub  may  be  given  with  the  patient  sitting, 
standing,  or  lying.  Slightly  moistened,  medium-fine 
salt  is  applied  over  different  areas  of  the  body.  Thia 
can  be  followed  by  a  spray  bath,  after  which  the  patient 
should  be  thoroughly  dried. 

The  prolonged  warm  immersion  bath  or  the  contin- 
uous bath  has  come  greatly  into  favor  in  the  manage- 
ment of  delirious  and  maniacal  patients.     By  a  special 


THE  NERVOUS  AND   THE  INSANE.  67 

ar^anu^ement  the  patient  is  gently  but  securely  restrained 
in"  the  bathtub,  into  which  water  is  constantly  running 
at  a  temperature  of  98°  or  100°F.  (See  Fig.  1.)  In  such 
a  bath  the  motor  restlessness  is  often  promptly  over- 
come and  the  insomnia  greatly  relieved.  The  filthy  are 
kept  clean  and  bedsores  are  prevented  or,  if  present, 
they  are  bpnefited.  Menstruation  is  no  contraindication 
and  tliere  is  no  danger  except  in  those  with  weak  hearts, 
who  of  course  should  have  special  care.  The  patient 
may  remain  for  days  in  the  bath,  eating  and  sleeping 
there.  I  f  it  happens  that  there  is  a  tendency  to  eczema, 
this  may  be  overcome  by  anointing  the  part.  When 
the  intervals  of  immersion  are  for  a  few  hours  at  a 
time,  the  bath  becomes  an  intermittent  one.  During 
these  baths,  if  the  patient  be  insane,  a  nurse  must  be  in 
constant  attendance. 

In  the  treatment  of  some  for ns  of  delirium  the  wet 
pack  is  of  great  value,  but  should  be  used  with  care. 

In  the  treatment  of  some  spinal  disorders,  as  myelitis, 
and  also  in  the  treatment  of  neuritis,  spinal  irritation, 
and  some  otlier  nervous  affections,  the  alternate  appli- 
cation of  very  hot  and  very  cold  water,  or  of  hot  water 
and  of  ice,  is  resorted  to  and  must  be  given  into  the 
hands  of  the  nurse.  This  treatment  is  carried  out  in 
one  of  two  different  ways.  On*  method  is  to  have  a 
basin  full  of  hot  water,  and  another  with  ice-water  and 
ice  broken  up  in  it.  A  spotige  is  dipped  into  the 
very  hot  water,  squeezed  out  quicklv,  and  rapidly 
passed  up  and  down  the  spinal  column  or  limbs ;  then 
another  sponge  is  dipped  into  the  cold  water  and 
same  procedure  is  used.    In  this  way  applica- 


68  THE  NURSING  AND  CARE  OF 

tions  first  of  the  hot  water  and  then  of  the  cold 
are  made,  usually  ten  minutes  or  more,  according  to 
directions.  Care  should  be  taken  in  using  these  local 
baths  not  to  expose  unnecessarily,  and  not  to  have  the 
water  dripping  or  running  all  over  the  patient.  As 
soon  as  the  operation  is  completed  the  patient  should 
be  rapidly  dried  and  made  comfortable.  If  the  opera- 
tion causes  an  undue  amount  of  shock,  that  fact  should 
be  reported  at  once  to  the  physician  for  further  advice. 
In  an  article  by  Allan  McLane  Hamilton,  M.D.,  on 
"  The  Use  of  Revulsives  in  Diseases  of  the  Nervous 
System,'^  published  in  the  Philadelphia  Medical  Times 
for  September  4, 1875,  is  described  an  ingenious  instru- 
ment for  the  alternate  application  of  dry  heat  and  dry 
cold,  a  most  valuable  form  of  revulsion  in  spinal  irrita- 
tion and  other  nervous  maladies.  It  consists  of  two 
chambers  of  brass,  three  inches  in  diameter  by  one  and 
a  half  inches  deep.  These  have  screw  plugs  inserted, 
so  that  they  may  be  removed  and  the  chambers  filled, 
one  with  cold  salt  and  water,  the  other  with  hot  water. 
These  chambers  are  fixed  on  a  rod  and  separated  by  an 
insulating  or  non-conducting  substance.  The  rod  ter- 
minates in  a  handle.  The  flat  surface,  covered  by  thin 
flannel,  is  placed  against  the  bare  back,  on  either  side 
of  the  spinous  processes  of  the  vertebrae,  and  the  in- 
strument moved  up  and  down  rapidly.  As  the  heated 
and  cold  surfaces  constantly  interchange,  the  effect  is 
marked. 


THE   NERVOUS  AND    THE   INSANE.  69 


70  THE   NURSING   AND    CARE    OF 


CHAPTER    I  Y. 

Forms  of  Electricity — Faradic  Apparatus — The  Mechanism, 
Management,  and  Care  of  Faradic  Apparatus — Hints,  Cau- 
tions, and  Contraindications  in  Using  Electricity — Electrodes 
— Conducting  Cords — Methods  of  Applying  Electricity — 
Motor  Points. 

In  the  present  chapter  I  shall  call  attention  to  the 
use  of  electricity  by  nnrses  ;  but  while  I  believe  nurses 
should  sometimes  be  allowed  to  use  this  agent,  I  wish 
to  have  my  position  with  reference  to  this  matter  clearly 
understood.  As  a  rule,  only  physicians,  or  others  under 
the  special  direction  of  physicians,  should  use  electricity 
for  medical  purposes.  Nurses,  therefore,  should  be  per- 
mitted to  make  use  of  it  only  under  special  orders  for 
particular  objects.  In  order  to  employ  electricity  in  all 
its  forms,  and  for  all  or  even  many  of  its  legitimate 
purposes,  no  one  is  qualified  thoroughly  unless  he  or 
she  has  received  a  regular  medical  training.  Certain 
dangers,  to  which  I  shall  recur  later,  attend  the  use  of 
electricity  in  the  treatment  of  disease  ;  and  some  of  these 
dangers  are  of  such  a  character  that  to  avoid  them  pre- 
su})poses  a  knowledge  of  the  physiology  of  the  nervous 
system  and  of  the  special  senses.  In  brief,  my  view  is 
that  in  a  certain  limited  number  of  cases,  under  the 
direction  of  the  doctor,  the  well-trained  nurse  may  be 
entirely  competent  to  use  electricity.     This  is  the  view 


THE  NERVOUS  AND   THE  INSANE.  71 

which  is  held  by  some  of  our  best  neurologists,  who  allow 
the-  nurses  who  have  charge  of  certain  of  their  patients 
to  make  electrical  applications  which  do  not  involve  any 
danger  or  require  any  unusual  knowledge.  It  is  well, 
therefore,  that  the  nurse  should  know  both  what  she 
can  do  and  what  she  ought  not  to  attempt.  It  is  a 
serious  mistake  for  any  one  not  properly  educated  in 
medicine  to  set  up  as  an  electrician.  I  have  known  of 
one  or  two  instances  in  which,  after  receiving  a  few 
directions  from  a  physician,  and  after  getting  a  few 
hints  from  a  mechanical  electrician,  the  nurse  has  im- 
agined that  she  had  the  whole  science  of  electro-thera- 
peutics at  command.  Woe  to  the  unfortunate  patient 
who  falls  into  the  hands  of  such  an  electrician  ! 

It  is  not  necessary  for  the  nurse  to  know  much  about 
the  physics  of  electricity, — that  is,  about  the  nature  of 
this  wonderful  force  or  about  the  principles  involved  in 
the  construction  and  action  of  batteries ;  neither  is  it 
requisite  that  she  should  have  a  profound  acquaintance- 
ship with  the  physiology  of  electricity, — that  is,  with  the 
science  which  treats  at  length  of  the  action  of  this  force 
upon  the  animal  tissues  and  organs.  She  should,  how- 
ever, at  least  understand  that  she  is  dealing  with  an  agent 
which  is  capable  of  doing  harm  as  well  as  good,  and 
which,  therefore,  requires  great  care  in  its  management. 

Electric  currents  are  used  in  medicine  as  a  means  of 
diagnosis  and  for  treatment.  The  former  is  not  within 
the  province  of  the  nurse  but  the  latter,  under  the 
guidance  of  the  physician,  may  be.  It  is  therefore 
essential  that  she  shall  have  some  knowledge  of  the 
currents  to  be  used,  the  apparatus  delivering  these  cur- 


72  THE  NURSING  AND   CARE  OF 

rents,  and  the  parts  of  the  body  where  the  application 
is  to  be  made.  The  forms  of  current  iu  common  use 
are  the  continuous,  the  interrupted,  and  the  alternating. 

The  continuous  current  flows  constantly  in  one  direc- 
tion. The  interrupted  current  also  flows  in  one  direction 
but  is  broken  at  regular  intervals.  The  alteruating 
current  flows  at  regular  intervals  first  in  one  direction 
and  then  in  the  other. 

The  current  may  be  derived  from  two  sources.  One 
of  these  is  the  current  used  for  lighting  streets  and 
houses,  and  the  other  is  from  the  concealed  cells  of  a 
portable  battery.  If  the  street  current  is  used  the  con- 
struction of  the  apparatus  will  vary  as  to  whether  the 
current  is  continuous  or  alternating.  If  available  the 
street  current  is  preferable,  since  the  cells  of  a  portable 
battery  may  become  exhausted  at  a  most  inopportune 
time. 

Static  electricity  is  used  by  specialists  to  a  limited 
extent  in  office  practice.  A  nurse  or  attendant  may  be 
required  occasionally  to  assist  the  physician  in  making 
applications  of  static  electricity — to  arrange  the  insulated 
stool,  to  revolve  the  plate,  to  assist  in  adjusting  the 
condensers,  or  even  in  part,  perhaps,  to  make  the  ap- 
plications. It  is  best  not  to  use  electricity  of  this  kind 
except  in  the  presence  of  a  physician  or  under  his 
direction. 

With  faradism  the  nurse  will  probably  have  more  to 
do  than  with  any  other  form  of  electricity.  A  faradic 
battery,  machine,  or  apparatus  (Fig.  2)  usually  consists 
of  a  cell  and  a  double  coil.  Some  faradic  machines  are 
made  with  several  coils,  but  most  of  them  have  but  two, 


THE  NERVOUS  AND   THE  INSANE. 
Fm.  2. 


73 


FARADIC   BATTERY. 

a  primary  and  a  secondary.  These  coils  are  unfortu- 
nately not  shown  in  this  instrument ;  but  one  surrounds 
the  other,  the  outer  being  called  the  secondary  and  the 
inner  the  primary.  Both  are  shown  in  what  is  some- 
times called  the  Dubois-Reymond  coil.  (Fig.  3.) 
Much  into  which  we  cannot  go  is  to  be  learned  scien- 
tifically about  a  faradic  instrument.  Its  current  is  not 
derived  from  a  number  of  cells.  No  faradic  battery 
needs  more  than  one  or  at  most  two  good  cells. 

The  faradic  batteries  are  provided  with  a  com- 
mutator or  polarity-changer,  and  with  a  slow  and 
rapid  rheotome  or  current-interrupter,  scales  by 
which  the  primary  and   secondary  currents  may  be 


74  THE  NURSING  AND   CARE  OF 

Fig.  3.  ^ 


DUBOIS-REYMOND  COIL  WITH  GALVANIC  APPARATUS. 

graduated  to  the  utmost  delicacy  or  greatest  power,  and 
with  a  special  form  of  galvanic  cell.  The  cells  now 
commonly  used  are  the  so-called  dry  cells.  They  are 
much  to  be  preferred,  because  there  is  no  danger  of 
damage  being  caused  by  acid  liquids.  They  are  put  into 
action  simply  by  bringing  a  switch  in  contact  with  a 
metallic  knob.  The  wet  cell  is  so  made  that  when  not 
in  action  the  zinc  is  raised  out  of  it  altogether,  and  the 
aperture  through  which  it  passes  covered  with  a  piece  of 
rubber  called  a  hydrostat,  making  the  cell  fluid-tight, 
and  saving  both  the  zinc  and  fluid  in  transportation. 


THE  NERVOUS  AND   THE  INSANE.  75 

The  Dubois-Reymond  coil  is  provided  with  slow 
and  rapid  interruptions,  with  a  switch  for  making  con- 
nections with  the  primary  and  secondary  currents,  and 
with  a  screw  for  regulating  the  tension  of  the  currents. 
Most  faradic  batteries  are  modifications  of  the  old. 

Let  me  now  give  somewhat  explicit  and  detailed 
directions  as  to  the  methods  of  using  a  faradic  machine. 
To  some  these  directions  may  seem  almost  too  detailed 
and  particular,  but  they  are  important  matters  which 
belong  to  the  province  of  the  nurse. 

To  start  a  faradic  current  is  a  simple  matter,  and  yet 
I  have  seen  it  bother  a  nurse  or  untrained  doctor.  Bat- 
teries by  different  manufacturers  are  started  in  somewhat 
different  ways,  but  all  are  on  the  same  general  principle. 
Understanding  the  method  of  starting  one,  the  nurse 
will  probably  have  no  trouble  with  another.  The  cell 
must  be  in  good  working  order. 

The  apparatus  shown  in  Fig.  2  is  supplied  with  a 
series  of  switches.  One  of  these  is  used  to  complete 
the  circuit  through  the  coils  and  cells,  and  also  as  a 
commutator  or  pole-changer.  This  switch  if  swung  to 
the  right  strikes  one  post,  if  to  the  left  another;  it 
must  be  in  contact  with  one  or  the  other. 

On  the  faradic  apparatus  for  office-table  (Fig.  4)  I 
will  explain  what  is  necessary  about  the  rheotome  or 
ourrent-interrupter  and  some  other  matters.  The  old 
batteries  had  only  one  form  of  interrupter,  a  spring 
lever  with  one  contact  screw.  This  spring  gave  only 
rapid  interruptions.  Some  new  instniments  are  made  in 
this  way,  but  this  is  a  mistake.  A  good  battery  should 
have  either  two  rheotomes  or  a  double  rheotome,  as  has 


76  THE  NURSING  AND   CARE   OF 

the  apparatus  shown  in  Fig.  4  one  for  slow  and  the 
other  for  rapid  interruptions.  The  rapid  interruptions 
are  rciade  by  an  ordinary  vibrating  spring  lever ;  the 
slow  by  a  long  lever  swung  horizontally  and  adjustable 
by  an  inclining  ring,  which  regulates  the  lever's  range 
of  vibration.  The  contact  screw  is  the  same  for  both 
levers,  which  are  at  right  angles  to  each  other.  It  is 
mounted  so  as  to  move  horizontally  across  the  angle  be- 
tween the  two  springs,  and  can  be  rapidly  swung  fi  om 
one  to  the  other  by  a  simple  movement.  The  method 
of  changing  from  slow  to  rapid  interruptions  is  worth 
knowing.  If  the  contact  post  is  moved  carelessly  it  is 
apt  to  scratch  the  spring.  The  operator  should  learn  to 
make  this  change  with  one  hand,  holding^  down  the  two 
springs  with  two  fingers  and  moving  the  bar  with  an- 
other or  the  thumb. 

If  a  very  rapid  interruption  is  desired,  the  contact 
post  is  brought  over  the  elastic  spring  (rapid  rheotome, 
Fig.  4)  and  then  gently  screwed  down  until  it  gets  to 
the  finest  point  at  which  can  be  had  any  interruption  at 
all.  If  it  is  screwed  down  too  far,  the  circuit  is  com- 
pleted so  as  not  to  allow  any  interruption.  If  a  mod- 
erately rapid  interruption  is  required,  the  screw  is  with- 
drawn to  a  more  and  more  remote  point  until  it  is  no 
longer  possible  for  any  current  to  pass.  If  a  slow^ly- 
interrupted  current  is  required,  the  post  is  swung  to  the 
long  lever  (slow  rheotome,  Fig.  4).  The  ring  surround- 
ing this  lever  may  be  placed  at  any  angle.  When 
placed  at  a  right  angle,  the  result  is  that  the  lever 
swings  through  the  largest  possible  arc,  and  the  slowest 


THE  NERVOUS  AND   THE  INSANE. 


77 


possible  interruption  is  obtained.  If  the  ring  is  ad- 
justed at  a  somewhat  acute  angle,  the  lever  is  no  longer 
able  to  move  in  a  large  arc,  and  the  rapidity  of  the  in- 
terruptions is  increased.     In  this  way  can  be  obtained 


Tig.  4. 


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Switch  to  ivQ:n':it-    '.r    ■•  t-sti- nrrh  ('Aiir.ripr  reirulator  of  current 

fur  prim  i-v  <•.)!.  strength. 

F ARABIC  APPARATUS  FOR  OFFICE  TABLE. 

intei  ruptions  from  one  per  second  u|)  to  hundreds  in  the 
same  time.  Batteries  are  not  all  made  like  the  one  hove 
shown.  In  one  battery  the  lever  moves  horizonially 
and  has  a  somewhat  different  arrangement  ;  in  another 


78  THE  NURSING  AND   CARE  OF 

an  inverted  cone  within  a  fork  constitutes  the  slow  in- 
terrupter. They  are  all  on  the  same  principle, — that  is, 
that  of  the  vibration  of  a  lever  in  a  greater  or  smaller 
arc.  The  rheotome  or  interrupter  sometimes  gets  out 
of  order.  The  elasticity  of  the  spring  is  sometimes 
impaired  by  bad  usage,  or  an  accumulation  of  dust  on 
the  spring  will  tend  to  make  an  irregular  current. 
Sometimes  the  point  of  the  contact  screw  is  worn  off 
and  needs  replacing. 

How  to  "  regulate^^ — that  is,  how  to  increase  or  de- 
crease the  current  strength — is  a  most  important  matter. 
Machines  from  different  manufacturers  have  apparently 
different  methods  of  regulating  the  current,  but  they 
are  all  on  similar  principles.  The  simplest  current- 
modifier  consists  of  a  copper  tube  sliding  over,  or  cov- 
ering to  any  desirable  length,  the  soft-iron  core  inside 
the  primary  coil.  It  acts  under  the  theory  that  when 
a  current  traverses  the  primary  coil  and  magnetism 
is  induced  in  the  soft-iron  core,  a  current  is  also 
induced  at  the  same  time  in  the  copper  tube,  which, 
being  a  closed  body  and  under  the  influence  of  the 
current,  acts  as  a  closed  coil.  When,  therefore,  the 
entire  length  of  the  copper  tube  covers  the  iron  core, 
the  current  induced  in  the  copper  tube  counteracts  and 
neutralizes  to  a  cert^ain  extent  that  elicited  in  the  primary 
coil ;  and  because  the  secondary  coil  depends  on  the 
inductive  force  of  thp  primary,  also  the  secondary  cur- 
rent. The  current  is,  therefore,  weakest  when  the  cop- 
per tube  covers  the  entire  core,  because  it  checks,  by 
induction  in  the  opposite  direction,  the  primary  current. 


THE  NERVOUS  AND   THE  INSANE.  79 

The. more  the  tube  is  withdrawn  the  larger  is  the  part  of 
the  coil  that  is  made  free,  the  current  becoming  stronger 
and  stronger  until  the  coil  is  freed  entirely  from  the  con- 
trainduction  of  the  tube.  This  mode  of  regulating  the 
current,  however,  is  not  entirely  satisfactory  for  the 
demands  of  a  good  faradic  coil  for  therapeutic  purposes, 
since  the  current,  even  with  the  tube-modifier  in  all  the 
way,  is  often  found  too  strong  for  application  to  sensi- 
tive nerves.  To  meet  such  cases,  the  entire  coil  is 
divided  up  into  sections,  or  tapped  at  different  lengths. 
First-class  batteries,  such  as  Flemming*s,  are  provided 
with  switch  arrangements,  by  means  of  which  any  one 
section  or  any  number  of  sections  may  be  used  at 
pleasure,  thus  opening  currents  hardly  perceptible  by 
switching  into  the  circuit  a  small  portion  of  the  coil,  or 
increasing  the  strength  by  adding  coils. 

Another  mode  of  regulating  the  current-strength  is 
found  in  the  DuBois-Reymond  induction  coil,  which, 
in  the  absence  of  a  copper  tube,  is  acted  upon  in  thiii 
regard  by  its  own  secondary  coil.  The  primary  coil 
with  the  iron  core  is  stationary,  while  the  secondary  coil 
is  made  to  slide  over  it.  When  the  secondary  coil 
covers  the  entire  length  of  the  primary,  the  primary  is 
weakest,  since  both  wire-ends  of  the  secondary  coil  are 
metallically  connected  together,  this  coil  becoming  one 
closed  body,  and  behaving  precisely  like  the  copper  tube 
enclosing  the  iron  core,  counteracting  induction.  By 
withdrawing  the  secondary  coil,  thus  releasing  a  larger 
area  of  the  primary  coil,  the  current  increases.  The 
reverse  action  takes  place  in  using  the  secondary  cur- 


80  THE  NURSING  AND    CARE   OF 

rent.  The  wire  connecting  the  two  coil-ends  is  re- 
moved, and  the  more  the  secondary  coil  is  pushed  in 
over  the  primary  the  more  inductive  surface  is  brought 
to  bear,  and  the  secondary  current  increases  in  propor- 
tion. 

Another  contrivance  for  diminishing  coarse  currents 
is  the  so-called  water-rheostat, — a  glass  tube  with  me- 
tallic bottom  and  top-ca])  in  which  is  a  movable  rod. 
When  the  tube  is  filled  with  water  and  one  terminal 
post  of  the  battery  is  joined  to  the  metallic  bottom,  and 
the  top  and  the  other  terminal  of  the  battery  connected 
with  the  electrodes,  the  current  is  forced  through  the 
column  of  water,  and  increases  in  strength  by  gradu- 
ally pushing  the  movable  rod  downwards  towards  the 
bottom. 

In  some  older  forms  of  batteries,  the  iron  core  i& 
made  inoval)Ie  and  is  used  as  a  moditier  ;  in  these  bat- 
tei'ies  the  cun'ent  is  weakest  with  the  core  out,  and  bv 
gradually  feedinu:  the  cure  in,  thus  pntting  more  of  its 
iron  mass  under  the  influence  «)f  induction,  the  curren: 
becomes  strono^er. 

It  the  battery  is  a  good  one,  ihe  operator  can  begin 
with  the  weakest  possible  current  and  increase  to  the 
strenu'th  necessai"v  without  dan^-er.  This  should  be  done 
bv  usin^  ilir  two  methods  of  reu:ulatinu-  the  strength  of 
the  curi'eni,  in  an  apparatus  in  which  the  tube  and 
switch  method.-  arc  b(»th  possible.  Supjiose  with  a  cer- 
tain })atient  it  is  necessary  to  be  very  careful  about  the 
use  of  the  battery.  The  patient  may  be  timid.  Some 
patients  imagine  that  when  the  battery  is  applied  they  are 


THE   NERVOUS   AND    THE   INSANE.  81 

going  to  have  a  thunderbolt  hurled  at  them.  The  best 
way  to  begin  in  such  a  case  is  to  increase  the  current  by 
the  use  of  the  hollow  cyliuder.  This  is  pulled  out 
slowly,  and,  when  a  certain  strength  of  current  is 
reached,  it  is  left  at  that  point.  If  necessary  to  with- 
draw the  cylinder  further  in  order  to  get  sufficient 
strength,  it  is  well  after  drawing  it  out  a  certain  distance 
to  return  it  and  push  the  switch  up  one  point.  The 
cylinder  can  then  again  be  withdrawn  if  necessary  ;  and 
later,  if  it  is  desired,  the  cylinder  can  be  once  more  re- 
turned and  the  switch  moved  to  another  knob. 

Let  me  now  give  a  hint  or  two  about  handling 
and  taking  care  of  a  faradic  battery.  One  that  is  well 
cared  for  should  not  often  get  out  of  order. 

The  nurse  should  be  able,  when  the  battery  is  not 
working  properly,  to  tell  whether  the  defect  is  in  the 
apparatus,  in  the  current-carriers,  or  in  the  electrodes. 
All  that  she  needs  to  do  is  to  moisten  the  fingers  and 
place  them  at  the  points  where  the  rheophores  are  con- 
nected with  the  instrument.  If  the  battery  is  all  right 
the  current  will  be  felt  passing  through  the  fingers. 
The  trouble  must  then  be  in  the  cords  or  in  the  elec- 
trodes. The  difficulty  is  frequently  to  be  found  in  the 
cords. 

When  the  apparatus  is  not  being  used  the  switches 
should  be  set  back  to  the  lowest  possible  strength, — the 
first  knob  of  the  semicircles.  This  is  an  important  rule, 
and  one  which,  I  am  sorry  to  say,  is  frequently  violated 
in  hospitals  and  elsewhere.  Remember  not  only  to  put 
the  switches  back,  but  also  to  push  in  the  cylinder-reg* 

6 


82  THE  NURSING  AND   CARE  OF 

ulator.  Keep  the  apparatus  clean  in  every  respect.  Re- 
move all  dirt.  If  anything  forms  through  corrosion  il 
should  be  removed. 

Harm  may  be  done  with  the  faradic  battery,  chiefly 
by  the  use  of  currents  of  too  great  strength.  Without 
going  into  scientific  details  with  reference  to  this  point, 
it  is  sufficient  to  say  that  while  nerve  and  muscle  can 
both  be  strengthened  and  restored  to  usefulness  through 
the  help  of  a  faradic  current,  on  the  other  hand,  if  such 
current  is  used  of  too  great  strength  or  for  too  long  a 
time  at  one  sitting,  nerve  and  muscle  may  be  exhausted 
by  the  enforced  overwork,  and  in  some  cases  wasting  or 
other  serious  trouble  ma/  result.  It  is,  therefore,  the 
duty  of  a  nurse  to  carefully  and  explicitly  attend  to  the 
directions  which  are  given  to  her  with  reference  to  the 
strength  of  the  current  and  length  of  the  application. 
The  temptation  with  one  not  thoroughly  posted  is  to 
rather  overdo  than  underdo  the  application  ;  and  patients 
themselves  sometimes  assist  in  bringing  about  this  re- 
sult by  their  natural  desire  to  get  the  most  out  of  the 
agent  that  is  being  used  for  their  relief  or  cure.  Neither 
singlu  muscles,  grouns  of  muscles,  nor  the  limbs  should 
be  subjected  to  currents  which  are  sufficient  to  twist 
and  contort  them  so  that  they  are  beyond  voluntary 
control.  If  a  faradic  current  is  applied  to  the  head, 
before  it  is  of  sufficient  strength  to  do  harm  the 
pain  produced  will  be  so  great  that,  as  a  rule,  patients, 
if  able  to  indicate  their  wishes  at  all,  will  not  allow  its 
further  use.  Owing  to  mismanagement  of  the  battery 
or  of  the  cords  or  electrodes,  however,  a  very  strong  cur- 
rent, possibly  the  full  force  of  a  coil,  may  accidentally  be 


THE  NERVOUS  AND    THE  INSANE.  83 

applied  to  a  patient's  head  or  neck,  or  other  part  of  the 
body,  and  cause  a  serious  jar,  contortion,  or  other  dis- 
turbance. Patients  who  are  unfamiliar  with  electricity 
should  always  be  handled  with  gentleness,  and  if  strong 
applications  are  required  these  should  be  gradually  led 
up  to  by  the  careful  use  of  the  graduators  or  regulators. 
Many  persons  have  a  deep-seated  dislike,  or  even  fear, 
of  electrical  applications,  and  this  is  not  best  overcome 
by  beginning  their  treatment  with  a  strong  shock.  The 
abdomen,  next  to  the  head  and  neck,  is  perhaps  the  most 
susceptible  part  of  the  body  in  making  faradic  or  other 
applications,  and  it  is  often  well  to  moderate  the  strength 
of  the  current  in  passing  from  applications  to  the  pos- 
terior part  of  the  trunk  or  limbs  to  the  abdominal 
muscles. 

The  galvanic  current  may  be  a  very  dangerous  one, 
and  its  use  by  the  nurse  is  most  limited  and  then  only 
under  the  guidance  and  direction  of  the  physician. 
Bearing  this  in  mind  the  current  may  be  used  to 
advantage  in  some  cases  of  neuralgia,  neuritis,  torti- 
collis, in  the  occupation  neuroses  and  sometimes  in 
paralysis.  Care  should  be  taken  that  the  current  is 
measured  by  the  galvanometer.  It  is  important  to  dis- 
tinguish between  the  anode  or  positive  pole  (-|-)  and 
the  cathode  or  negative  pole  ( — ).  This  may  be  done  by 
placing  the  two  ends  of  the  conducting  wires  about  an 
inch  apart  in  water  when,  with  the  current  turned  on, 
quite  a  quantity  of  bubbles  will  appear  at  the  end  of 
the  wire  known  as  the  negative  pole.  Another  method 
is  to  bring  the  ends  of  the  charged  wires  in  contact  with 
wet  blue  litmus  paper  and  the  positive  pole  will  turn 
the  blue  color  red. 


84  THE  NURSING  AND   CARE  OF 

The  term  electrode  or  pole  is  given  to  the  instru- 
ment ^vith  which  electricity  is  applied  to  the  patient. 
The  term  rheophore  or  current-carrier  is  sometimes 
used  to  indicate  the  same  appliance,  but  it  is  more  prop- 
erly employed  to  designate  the  flexible  conductors  or 
cords  which  go  from  the  binding  post  of  the  battery  to 
the  electrodes  or  handles.  I  shall  here  confine  myself 
to  a  few  practical  general  remarks  about  electrodes  and 
rheophores,  but  may  say  more  about  them  when  I  come 
a  little  later  to  speak  of  the  methods  of  applying  elec- 
tricity to  different  portions  of  the  body.  Electrodes 
are  large  or  small ;  they  are  of  different  shapes,  and  are 
designed  for  making  application  to  various  organs  and 
parts, — to  the  skin,  muscles,  nerves,  joints,  internal  or- 
gans, etc.  As  a  rule  nurses  will  not  be  called  upon  to 
use  the  more  special  forms  of  electrodes  for  internal  ap- 
plications, as  to  the  throat,  bladder,  urethra,  or  uterus. 
It  is  beyond  their  province  to  make  such  applications ; 
therefore,  it  is  not  worth  while  to  study  the  forms  of  elec- 
trodes used  for  these  purposes.  They  will  be  concerned 
only  with  the  use  of  the  commoner  forms  of  electrodes. 
These  are  usually  disks  of  metal  or  carbon  connected 
by  a  screw  with  wooden,  vulcanite,  or  other  insulating 
handles.  They  are  also,  of  course,  joined  to  the  con- 
ducting cords  which  run  to  the  battery.  The  nurse 
should  know  how  to  select  the  best  form  of  electrode 
for  accomplishing  certain  purposes  under  the  direction 
of  the  physician.  When,  for  instance,  an  application 
is  to  be  made  beneath  a  patient^s  clothing,  a  good  form 
of  electrode  is  one  in  which  the  disk  is  in  the  same 
plane  as  the  handle.     In  most ,  electrodes  the  plane  of 


THE  NERVOUS  AND    THE  INSANE. 


85 


the  disk  is  at  right  angles  to  that  of  the  handle,  and 
this  makes  it  inconvenient  to  slip  beneath  the  clothing, 
Never  use  a  sponge  or  moistened  electrode  of  any- 
kind  which  is  not  clean.  It  ought  to  be  unnecessary  to 
say  this,  but  it  is  a  rule  that  is  sometimes  violated.  If 
the  nurse  is  making  a  series  of  applications  to  the  same 
patient,  it  may  not  be  objectionable  to  use  the  same 

Tig.  5. 


BOX   OF   ELECTRODES. 


electrodes  continuously ;  but  even  in  such  a  case  the 
coverings  should  be  cleaned  after  each  application.  They 
should  be  washed  thoroughly  in  warm  water,  or  with 
some  form  of  corrosive  sublimate  or  carbolic  soap, 
or  other  good  cleansing  material.  After  a  time  elec- 
trodes may  become  incrusted  from  being  dipped  into 
salt  solutions,  or  certain  chemical  deposits  may  take 
place  on  them.     These  deposits  on  the  surface  of  the 


86  THE  NURSING  AND   CARE   OF 

electrodes  may  cause  local  electrical  actions,  and  render 
the  application  unnecessarily  painful.  A  clean,  polished 
electrode  is,  therefore,  less  painful  than  any  other. 

A  neat  method  of  covering  an  electrode,  suggested 
by  Dr.  G.  B.  Massey,  of  Philadelphia,  is  to  employ 
absorbent  cotton  instead  of  chamois  skin  or  sponge. 
Take  a  piece  of  clean  absorbent  cotton,  fold  and  twist 
it  over  the  disk  of  the  electrode,  and  wet  it.  It  will 
cling  to  the  disk,  and  after  the  application  it  may  be 
thrown  away  and  a  fresh  piece  used  every  time. 

Physicians  and  nurses  should  learn  to  hold  the  elec- 
trodes in  an  easy  and  advantageous  manner ;  if  possi- 
ble, both  should  be  held  in  one  hand.  This  is  important 
for  various  reasons.  It  leaves  the  other  hand  free  to 
regulate  the  strength  of  the  current  and  for  other  pur- 
poses. In  direct  muscular  applications,  and  in  all  others 
in  which  it  is  possible  to  hold  electrodes  in  one  hand, 
this  should  be  done  in  a  certain  way.  They  should  be 
held,  pointing  backwards,  the  handle  of  one  electrode 
between  the  index  and  middle  finger,  and  that  of  the 
other  between  the  ring  and  little  finger,  as  shown  in 
Fig.  6. 

Held  in  this  way,  the  disks  can  be  brought  very  close 
together,  or  can  be  separated  several  inches.  Almost 
the  entire  length  of  the  forearm  or  upper  arm  can  be 
included  between  the  electrodes  thus  held  in  one  hand, 
or  by  shifting  one  of  them  between  the  thumb  and 
index  finger.  The  nurse  should  practise  employing 
one  hand  wherever  it  is  possible. 

It  is  not  unimportant  to  know  something  about  the 
connecting  cords  which  are  used  in  making  electric 


THE  NERVOUS  AND    THE  INSANE.  87 

applications.  A  good  conducting  cord  should  have  cer- 
tain qualities.  It  should  be  flexible,  not  easily  broken, 
and  capable  of  being  easily  repaired.  The  operator 
should  know  how  to  detect  any  break  or  defect  in  the 
cord.  Most  conducting  cords  are  made  either  of  tinsel 
or  of  more  or  less  flexible  copper  wire.  If  it  is  found 
that  the  current  is  not  being  conveyed  properly,  the  cords 
should  be  looked  at,  particularly  at  the  points  where  the 

Fig.  6. 


METHOD  OF  HOLDING  ELECTRODES  IN  ONE  HAND. 

wires  are  attached  to  the  terminal  pins.  The  best  cord 
is,  I  think,  a  somewhat  flexible  twisted  copper  wire, 
insulated  and  attached  to  the  pins  in  a  peculiar  manner 
by  double  eyelets.  The  practical  thing  to  do  is  to  have 
two  sets  of  cords, — one  of  insulated  flexible  wire,  the 
other  several  yards  of  "  cable  wire."  I  generally  have 
three  or  four  yards  of  this  "  cable  wire''  in  the  drawer 
of  the  battery  box,  and  then  I  am  not  at  a  loss  if  the 
cords  should  break.  This  cable  wire  is  copper  wire  about 
No.  16  or  17,  covered  with  gutta-percha.  If  it  breaks, 
all  that  it  is  necessary  to  do  is  to  scrape  off  the  gutta- 


88  THE  NURSING  AND   CARE  OF 

percha  and  repair  it.  To  shorten  it,  it  can  be  broken 
at  any  point. 

In  taking  up  the  methods  of  applying  electricity  I 
shall  restrict  myself  to  those  which  are  in  most  common 
use, — those  which  should  alone  be  employed  by  the 
nurse  under  competent  direction.  I  shall  discuss  appli- 
cations to  the  muscles,  nerves,  skin,  joints,  and  limbs, 
and  in  addition  to  these  certain  general  methods  of 
treatment.  Nurses  will  chiefly  have  to  deal  with 
neuro-muscular  applications, — applications  to  nerves 
and  muscles. 

To  make  a  deep-seated  application  to  a  muscle  or 
nerve  the  electrode  should  be  moistened  or  wet.  It  was 
discovered  by  Duchenne — although  it  seems  so  small 
a  matter  that  it  can  hardly  be  spoken  of  now  as  a  dis- 
covery— that  an  application  can  be  restricted  or  limited  to 
the  skin  by  the  dry  method,  and  that  by  the  wet  method 
the  skin  can  be  almost  entirely  neglected  and  the  deeper- 
seated  parts  reached. 

In  making  applications  to  muscles  or  to  nerves  sup- 
plying muscles,  in  cases  of  paralysis,  two  different  meth- 
ods, known  as  the  direct  and  the  indirect  methods,  or 
direct  muscular  electrization  and  indirect  muscular  elec- 
trization, are  commonly  used.  In  direct  applications 
the  electrodes  are  applied  as  directly  as  possible  to  the 
muscles.  In  the  indirect  method  the  muscle  is  caused 
to  contract  through  the  nerve  or  nerves  which  supply 
it.  In  order  to  understand  the  indirect  method  it  is 
necessary  to  know  something  about  motor  points. 
These  are  points  where  the  nerves  which  supply  the 
muscles   are   most  readily  reached   by  the   electrodes. 


THE  NERVOUS  AND   THE  INSANE,  89 

They  are  points  where  the  nerve  bends  round  the  mus- 
cle, or  dips  beneath  it,  or  passes  into  it,  or  comes  out  of  it. 

To  a  certain  extent  motor  points  can  be  studied 
readily  by  any  one.  Placing  one  electrode  at  any  con- 
venient place,  as  on  the  sternum  or  along  the  spine,  and 
then  gliding  over  any  selected  muscle,  a  point  is  found 
where  it  contracts  most  readily.  This  is  the  motor 
point  for  this  muscle.  No  difficulty  should  be  experi- 
enced in  this  matter  after  consulting  illustrations  7,  8, 
9,  10,  11,  and  12.  Suppose  we  have  a  case  of  so- 
called  wrist-drop ;  the  hands  hanging  limp  from  want  of 
power  in  some  of  the  muscles  of  the  forearm.  The  elec- 
trode is  placed  atone  point  and  the  hand  moved  inwards  ; 
at  another  it  moves  outwards,  but  the  movement  desired 
is  upward,  and  finally  a  point  is  found  where  extension 
or  lifting  of  the  hand  is  produced.  Certain  movements 
belong  to  the  foot, — upward  or  downward  flexion  or  ex- 
tension, and  certain  combinations  of  directions,  as  out- 
wards and  upwards,  inwards  and  upwards,  inwards  and 
downwards,  etc.  It  is  necessary  to  know  in  a  general 
way  where  the  muscles  producing  these  movements  are 
situated ;  then,  if  a  certain  form  of  paralysis  is  to  be 
treated,  the  operator  will  soon  learn  to  what  points  the 
electrodes  should  be  applied  in  order  to  do  the  most 
good.  Something  should  also  be  known  of  the  muscles 
producing  thegeneralmovementsof  the  limbs  and  trunk. 

I  will  give  a  few  hints  and  cautions  about  muscular 
applications.  In  the  first  place,  the  operator  should  be 
satisfied  to  make  a  moderate  application,  and  thus  avoid 
one  of  the  mistakes  often  made  by  the  nurse,  and  some- 
times by  the  physician.     If  the  contraction  is  distinctly 


90  *       THE  NURSING  AND    CARE   OF 

visible,  it  is  sufficient.  The  patient  will  often  urge  the 
Qurse  or  physician  to  use  more,  on  the  principle  that  if 
a  little  will  do  good  a  larger  quantity  will  do  more 
good.  The  limbs  should  not  be  violently  contorted, 
nor  should  the  applications  be  continued  too  long. 
General  faradization,  to  be  described  later,  if  done  skil- 
fully, either  by  the  lying  or  the  sitting  method,  can  be 
completed  in  from  twenty  to  forty  minutes.  The  nurse 
simply  passes  rapidly  from  one  muscle  to  another,  or 
one  muscular  group  to  another,  producing  contractions 
for  a  few  seconds.  If  the  application  is  continued 
too  long,  or  made  too  severe,  it  may  cause  exhaustion 
and  even  wasting.  Although  these  patients  may 
improve  for  a  time,  the  benefit  will  not  be  lasting. 
One  reason  why  electricity  is  often  unsuccessful  is  be- 
cause doctors  and  nurses  are  slipshod  in  its  use.  It  is 
not  always  an  interesting  matter  to  apply  electricity, 
but  any  one  who  does  not  intend  to  do  it  properly 
should  not  attempt  it  at  all. 

Electricity  should  never  be  used  soon  after  meals, 
for  electrical  applications  may  interfere  with  digestion. 
The  preferable  time  is  midway  between  meals,  or  as 
far  away  from  meals  as  possible. 

Another  practical  point  is  that  electricity  should 
never  be  applied  to  a  limb  or  muscle  which  is  in  a  tense 
condition.  The  muscles  should  always  be  relaxed,  but 
the  opposite  of  this  is  frequently  the  case.  The  patient 
will  stretch  the  arm  to  its  full  length,  or  will  stand 
while  electricity  is  applied  to  the  back  of  the  leg  and 
calf.  This  is  improper.  If  the  patient  is  standing  at 
all,  the  application  should  be  made  to  one  leg  while  the 


f/ 


..^ 


.  \'( 


Xv 


»  «  d  ^  ~, 


Tri. 


\N 


<ii.. 


'/-'- 


.^-,  e»  «' 


Fig.  7. 


TH.  brachioradialis 


///.flexor  carpi  rad. 
tn.  palmar,  lun^jus 

„!.  flexor  carpi  uln. 


»«.  flexor  poll.  long. 


tn.  pronator  quadr. 
jV.  inedianus 


til.  abduct,  roll 
brev 

tn.  flexor  poll,  brev 


m.  triceps  (common 
point) 


w/.  pronator  teres 


tn.  flexor  diijitorum 
sublimis 


A',  ulnaris 

VI.  abductor  dig.  V. 
mm.  lumbricales 


w.    adductor  jollic. 

MOTOR  POINTS  AND  MUSCULATURE  OF  ARM;  ANTERIOR  SURFACE. 


Fig.  8. 


t>i.  infraspinat 


*n.  teres  minor 


m.  teres  iiajor 


fn.  latiss.  don> 


caput  inedule  tn 
tricip 


m.  ancooaeus 


»/».  flexor  carpi  ulii 

"I.  extensnr  carpi 
rad.  brevii 

"I.  extensor  carpi 

till)., 

"I.  flexor  dliflioruni 

profundus 


"t.  extent.  di|».  ; ' 

"t.  indicator 
tn.  aWuctor  dij;-  ' ' 


»'.  deltoideus  (post 
port.) 


"/.  drltoideiis  {mid- 
dle port.) 


caput  iont;uiu  wi. 
tricip. 


w    tri.  eps    (median 
and  lateral  head) 


m.  bracliioradialls 


WT.     e-xtenvir    carpi 
rad.  lon^. 


f'ltn.  interossei 
dorsales 


m   evien«or  dit;itnr. 
coniiii. 


'»   adductor  pullicis 


MOTOR  POINTS  AND  MUSCULATURE  OF  ARM;   POSTERIOR  SURFACE. 


■m.  tensor  fasc.   lat. 


171.  sartorius 

7H.  quadriceps 

(common    point   lor 

}/t.    rectus    et   vast. 

lat.) 


?M.  vastus  lateralis 


N-  obturatorius 


tn.  adduct.  long. 
>«.  trracilis 


»i.  rectus  feuiorls 
>ti.  adduct  niagn. 


m.  vastus  inedialis 


MOTOR  POINTS  AND  IMUSCULATURE  OF  THIGH; 
ANTERIOR  SURFACE. 


Fig.  10. 


ni.  adduct.  magn. 
■m.  semitendin. 


>n.  seiuimembr. 


.V.  tibialis 


>n.  gliitaeus  med. 


»i.  glutaeus  max. 


m.  biceps  femoris 


y.  peroneus 


MOTOR  POINTS  AND  MUSCULATURE  OF  THIGH; 
POSTERIOR  SURFACE. 


Fig.  11. 


y.  peroneus 


w.  extensor  dig', 
longus 


jn.  peroneus  brevis 


}n.  extensor  halluc. 
long. 


m.  extensor  digitor. 
brevis 


tn.  gastrocnemius 
m.  peroneus  longus 
fn.  tibialis  anterior 


nt.  soleus 


m.  extensor  halluc, 
brevis 


MOTOR  POINTS  AND  MUSCULATURE  OF  LEG; 
ANTERIOR  SURFACE. 


N-  tibialis 


?«.  gastrocnem. 


i\\  tibialis 


N.  peroneus 


tn.  soleus 


>n.  flexor  digitor. 
long. 

7n.  flexor  halluc. 
long 


MOTOR  POINTS  AND  MUSCULATURE  OF  LEG; 
POSTERIOR  SURFACE. 


THE  NERVOUS  AND    THE  INSANE.  91 

weight  is  borne  on  the  other ;  it  is  better  to  have  the 
patient  lying  down.  So  in  the  arm  it  is  well  to  have 
the  arm  raised  half-way,  so  that  the  muscles  shall  be 
relaxed.  The  affected  arm  may  be  supported  by  the 
well  hand. 

Faradic  electricity  will  do  for  muscular  applications 
in  most  cases ;  it  will  do  in  all  cases  of  paralysis  due  to 
a  central  lesion ;  it  will  answer  in  all  cases  where  the 
muscles  respond  readily  to  it.  If  the  affection  is  due 
to  rheumatism,  injury,  lead-poisoning,  or  other  so-called 
peripheral  cause,  producing  what  the  doctor  calls  a  pe- 
ripheral paralysis,  it  will  be  difficult  or  impossible  to 
get  a  response  with  faradism,  and  galvanism  will  have 
to  be  used. 

In  making  applications  of  electricity  to  the  muscles 
of  the  face  it  is  important  to  proceed  with  great  care. 
The  current  which  is  applied  should  not  be  too  strong, 
and  its  strength  should  be  very  slowly  and  cautiously 
increased.  In  such  application  it  is  necessary  to  use 
small  motor-point  electrodes,  as  it  is  impossible  to  reach 
the  individual  muscles  unless  the  electrodes  are  small. 
One  pole  is  placed  upon  an  indifferent  part,  or  as  near 
as  possible  to  the  point  where  the  nerve  emerges  from 
the  skull.  Nurses  should  never  make  these  applications 
except  by  explicit  orders  and  under  observation. 

In  making  an  application  to  the  skin,  a  rapidly-inter- 
rupted faradic  current  is  usually  preferred  by  the  phy- 
sici?n,  although  a  galvanic  current  may  sometimes  be 
usea.  A  metaric  electrode  should  always  be  used, — 
unless  other  directions  are  received,— a  brush,  or  one  of 
the  uncovered  disks  already  shown.     One  of  the  eleo- 


92  THE  NURSING  AND    CARE  OF 

trodes  is  to  be  moistened  and  the  other  may  be  a  wire 
brush.  The  moistened  electrode  is  to  be  placed  at  an 
indifferent  spot,  as  on  the  sternum,  at  the  lower  part  of 
the  spinal  column,  over  the  knee-pan,  or  at  the  upper  part 
of  the  thigh.  The  important  electrode  is  the  dry  one. 
The  surface  to  be  treated  with  the  metallic  brush  or 
disk  should  be  gone  over  rapidly.  A  large  brush  elec- 
trode should  be  used  where  a  large  extent  of  the  skin  is 
to  be  treated. 

Another  way  of  making  applications  to  the  skin, 
particularly  to  the  skin  of  the  face  and  head,  is  by  the 
hand ;  and  this  is  the  only  sort  of  application  that  the 
nurse  should  be  allowed  to  make  to  the  head.  One 
electrode  is  put  into  the  hand  of  the  patient  and  the 
other  taken  in  the  hand  of  the  operator,  and  the  free 
hand  of  the  latter,  dry,  is  then  passed  over  the  skin 
of  the  face,  neck,  and  head.  The  back  or  front  of  the 
hand  may  be  used. 

If  it  is  desired  to  make  an  application  to  a  joint,  this 
may  be  done  in  two  ways.  One  is  to  take  two  broad, 
wet  electrodes,  or  one  large  and  one  small  electrode, 
and,  placing  one  on  one  side  of  the  joint  and  the  other 
on  the  opposite  side,  allow  the  current  to  pass  through 
the  part.  Another  method,  which  is  useful  in  apply- 
ing electricity  to  the  joints  of  the  foot,  is  to  take  a 
basin  of  warm  water  to  which  a  little  salt  has  been 
added,  and  place  the  electrode  in  the  water.  The  foot 
is  immersed  in  the  water  and  the  other  electrode  applied 
to  some  portion  of  the  limb. 

Nurses  may  be  called  upon  to  make  applications  to 
all,  or  nearly  all,  parts  of  the  body.    This  so-called  gen- 


THE  NERVOUS  AND    THE  INSANE.  93 

eral  faradization  may  be  used  upon  the  patient  either  in 
bed  or  sitting  up.  In  what  is  commonly  termed  the  "  rest 
treatment" — the  treatment  by  seclusion,  rest,  massage, 
and  electricity — the  electricity  is  applied  to  all  parts  of 
the  body  in  succession,  the  patient  remaining  in  bed. 
Well-wetted  electrodes  are  used,  either  sponges  or 
absorbent  cotton,  which  are  dipped  in  warm  water  to 
which  in  some  cases  a  little  salt  may  be  added.  The 
patients  for  whom  the  rest  treatment  is  appropriate 
usually  have  no  changes  in  the  nerves  and  muscles 
which  would  call  for  any  particular  selection  of  the 
galvanic  or  faradic  current ;  in  other  words,  the  nerves 
and  muscles  commonly  respond  readily.  For  this  reason 
the  faradic  current  which  is  most  readily  managed  and 
applied  is  most  resorted  to  in  these  cases.  Beginning 
with  the  limbs,  preferably  the  lower  extremities,  the 
electrodes  are  applied  either  directly  over  the  muscles  or 
to  the  motor  points.  Care  must  be  taken  to  include  as 
far  as  possible  every  muscle  and  group  of  muscles  in  the 
application.  Contraction  is  first  caused  in  the  muscles 
which  move  the  toes  and  foot ;  next  the  operator  passes 
to  the  legs  and  thighs,  taking  in  each  set  of  muscles  in 
turn, — ^the  posterior,  anterior,  outer,  and  inner.  Having 
completed  the  application  to  the  lower  extremities,  the 
upper  limbs  are  next  faradized,  beginning  with  the  fin- 
gers and  bands  and  ascending  to  the  shoulders.  The 
muscles  of  the  back,  chest,  and  abdomen  are  treated 
last.  Sometimes  it  is  advised  to  treat  the  muscles  of 
the  back,  loins,  and  abdomen  before  the  upper  extrem- 
'ties.     Perhaps  it  makes  but  little  difference  as  to  this 


94  THE  NURSING  AND    CARE   OF 

matter,  but  on  the  whole  I  believe  it  is  most  convenient 
usually  to  leave  these  until  the  last.  The  strength  of 
current  should  be  just  sufficient  to  produce  visible 
movement  of  the  muscles.  Violent  contorting  of  the 
muscles  should  be  carefully  avoided.  From  time  to 
time  the  electrodes  should  be  re-moistened,  care  being 
taken  always  to  squeeze  out  the  water  thoroughly  in 
order  not  to  have  it  trickle  over  the  patient.  Applica- 
tions are  not  made  to  either  the  head  or  the  neck  unless 
they  are  especially  directed.  In  making  applications 
to  the  shoulders  and  chest,  care  should  be  taken  not  to 
place  the  electrodes  carelessly  over  the  side  and  front 
of  the  neck. 

The  second  method  of  general  faradization — that  used 
upon  the  patient  in  a  sitting  position — is  a  method  often 
employed  by  physicians  in  their  offices,  and  may  some- 
times be  used  by  nurses  under  direction.  Drs.  Beard 
and  Rockwell  were  among  the  first  to  make  this  method 
popular.  According  to  them,  the  use  of  a  faradic  cur- 
rent for  half  an  hour  or  less  daily  has  a  decidedly  tonic 
effect  upon  the  nervous  system.  Other  observers  believe 
this  observation  to  be  correct,  hence  electricity  is  fre- 
quently used  in  this  way.  The  special  mode  of  treat- 
ment differs  a  little  according  to  choice  or  convenience. 
One  method  is  to  place  in  the  hand  of  the  patient  one 
of  the  well- wetted  electrodes ;  the  other  is  at  first  held 
by  the  operator,  who  with  his  free  hand  makes  appli- 
cation to  the  head,  face,  and  neck.  A  weak  rapidly- 
interrupted  primary  current  is  usually  employed.  After 
this  careful  application  to  the  head,  face,  and  neck  has 
been  made,  the  patient  still  keeping  the  electrode  in  the 


THE  NERVOUS  AND    THE  INSANE.  95 

hand,  the  operator  passes  down  the  back  and  arm  with 
the  other  electrode.  The  patient  then  shifts  the  elec- 
trode to  the  opposite  hand  and  the  operator  passes  down 
the  arm  of  this  side.  Both  electrodes  can  be  taken  into 
the  hand  of  the  operator  and  rapidly  passed  or  glided 
over  the  arms  and  trunk.  The  lower  extremities  are 
treated  last.  A  good  plan  is  to  have  first  one  foot  and 
then  the  other  placed  upon  a  flat  electrode,  or  both  feet 
can  be  placed  upon  a  large  metallic  electrode  covered 
with  moistened  cloth  or  chamois  skin ;  with  the  other 
electrode  the  operator  passes  carefully  over  all  accessible 
portions  on  the  lower  extremities.  Instead  of  this 
method  it  is  sometimes  more  convenient  to  keep  one 
electrode  upon  the  lower  portion  of  the  back,  while  the 
other,  passed  under  the  clothing  from  below,  is  applied 
to  muscles  and  muscular  groups  in  succession  from  the 
feet  to  the  hips.  At  certain  positions,  as  under  the  knee, 
the  large  nerve-trunks  are  more  accessible  than  else- 
where, and  by  occasionally  applying  the  electrode  in 
these  positions  any  muscles  which  may  have  been 
omitted  in  the  direct  application  can  be  reached  more 
or  less  thoroughly,  according  to  the  current's  strength, 
by  way  of  the  nerve  supply.  Unnecessary  exposure 
should  be  carefully  avoided.  A  little  ingenuity  and 
forethought  will  often  enable  the  operator  to  make  his 
entire  application  with  comparatively  little  exposure. 


96  THE  NURSING  AND   CARE   OF 


CHAPTER   V. 

The  Nursing  and  Care  of  the  Insane. 

With  reference  to  many  matters  that  are  sometimes 
included  in  the  published  or  oral  instructions  which  are 
given  to  nurses  and  attendants  upon  the  insane,  it  is 
not  my  purpose  to  deal  in  the  present  chapter.  In  other 
works  upon  nursing — surgical  and  medical  treatises 
in  particular — specific  directions  are  given  with  refer- 
ence to  many  things  necessary  to  be  known  by  those  who 
are  in  attendance  upon  the  injured  or  sick,  whether  sane 
or  insane ;  such  as  dislocations  and  fractures ;  sprains, 
wounds,  and  hemorrhages;  artificial  respiration;  the 
use  of  compresses,  poultices,  stupes,  and  fomentations ; 
the  treatment  of  bed-sores  and  ulcers. 

Very  little  has  been  published  with  reference  to  the 
nursing  and  care  of  the  insane,  except  what  may  be 
found  under  the  head  of  treatment  in  the  general  text- 
books on  insanity.  Two  small  books  have  appeared 
within  a  few  years,  one  in  Great  Britain  and  one  in 
this  country.  The  first,  entitled  "  A  Hand-Book  for 
the  Instruction  of  the  Attendants  on  the  Insane,^^  was 
prepared  by  a  sub-committee  of  the  British  Medico- 
Psychological  Association,  appointed  at  a  branch  meet- 


THE  NERVOUS  AND   THE  INSANE.  97 

ing  held  in  Glasgow  on  February  21,  1884,  and  has 
been  published  in  this  country  by  Cupples,  Upham 
&  Co.,  of  Boston.  It  contains  much  useful  information 
and  valuable  instruction,  but  too  much  attention  is  de- 
voted to  the  consideration  of  elementary  anatomy  and 
physiology.  A  more  valuable  work  is  entitled  "  How 
to  Care  for  the  Insane.  A  Manual  for  Attendants  in 
Insane  Asylums,''  by  W.  D.  Granger,  M.D.,  First 
Assistant  Physician  in  the  Buffalo  State  Asylum  for 
the  Insane,  and  published  by  G.  P.  Putnam's  Sons,  New 
York  and  London.  I  have  obtained  from  both  of  these 
books  some  valuable  facts,  hints,  and  suggestions ;  but 
most  of  my  remarks  will  be  based  upon  observation 
and  experience,  and  upon  information  obtained  directly 
from  specialists,  and  from  the  medical  officers  and  at- 
tendants of  insane  hospitals  with  which  I  have  been 
connected  as  consultant. 

While  a  knowledge  of  such  subjects  as  the  anatomy 
and  physiology  of  the  nervous  system  and  the  nature 
of  the  different  forms  of  insanity  may  be  of  value  to 
nurses  and  attendants,  it  is  not  strictly  necessary  that 
they  should  be  fully  informed  about  such  matters. 
There  is,  indeed,  a  certain  danger  that  if  too  much  at- 
tention is  paid  in  the  instruction  of  nurses  and  attend- 
ants to  subjects  which  belong  in  strictness  to  a  true 
medical  education,  they  may  make  the  mistake — a  not 
infrequent  one  among  them — of  supposing  that  they 
are  the  doctors.  The  information  absolutely  necessary 
for  nurses  to  have  about  the  structure  and  functions  of 
the  nervous  system  can  be  compressed  into  a  very  small 
oompass.     It  is  necessary  that  they  should  know  that 

7 


98  THE  NURSING  AND   CARE  OF 

the  brain — with  the  details  of  the  treatment  of  whose 
diseases  they  are  sometimes  intrusted — is  an  organ  which, 
although  deeply  seated  within  a  thick  and  strong  bony 
chamber,  is  subject,  through  the  multitude  of  nerves 
which  put  it  into  communication  with  the  outside  world, 
to  impressions  which  soothe,  annoy,  comfort,  distress, 
or  irritate. 

It  is  well  that  nurses  and  attendants  upon  the  insane 
should  have  some  knowledge  as  to  the  forms  of  insanity 
and  the  special  symptoms  exhibited  by  certain  patients ; 
but,  as  already  intimated,  this  knowledge  need  not  be 
very  extensive  nor  profound,  though  it  should  be  exact  as 
far  as  it  goes.  When  it  is  remembered  that  even  edu- 
cated physicians,  unless  they  have  spent  some  time  in 
the  special  study  of  insanity,  have  considerable  diffi- 
culty in  separating  the  different  forms  of  insanity,  it  is 
easy  to  be  seen  that  it  would  be  folly  for  an  individual 
who  is  not  medically  educated  to  try  in  a  little  brief 
instruction  to  obtain  such  information.  The  superficial 
features  of  a  case  will  not  enable  an  opinion  to  be 
reached  as  to  its  nature.  Thus  in  melancholia,  which 
is  a  form  of  mental  disease,  the  essential  feature  of 
which  is  emotional  depression,  a  patient  sometimes  has 
the  violent  outbreaks  of  agitation  or  excitement  which 
are  really  the  result  of  depression ;  and,  conversely,  a 
patient  suffering  from  true  mania  may,  for  brief  inter- 
vals, be  in  a  state  of  great  moodiness  and  depression. 
We  might  illustrate  by  references  to  other  well-known 
forms.  What  a  nurse  should  know  is  that  there  are 
certain  great  divisions  of  diseases  of  the  mind  which 
give  special   symptoms,   and    that  patients   must  be 


THE  NERVOUS  AND   THE  INSANE.  99 

cared  fbr  in  this  way  or  in  that  according  as  they  suffer 
frofn  one  or  the  other  of  these  forms. 

The  doctor  having  once,  in  the  presence  of  the  nurse 
or  attendant,  clearly  made  the  diagnosis  of  the  form  of 
mental  trouble,  the  latter,  knowing  this,  should  bear 
certain  facts  in  mind :  should  remember,  for  instance, 
that  a  case  of  melancholia  is  likely  to  be  suicidal  or  to 
starve  to  death ;  that  one  of  mania  is  not  infrequently 
homicidal  or  destructive ;  that  one  of  monomania  may 
exercise  duplicity  and  may  suppress  for  a  time  his  de- 
lusions ;  that  a  dement  is  likely  to  be  filthy  and  not  to 
take  care  of  himself  in  any  way ;  that  an  insane  epileptic 
may  one  minute  be  peaceful  and  serene  and  the  next 
may  be  in  a  most  dangerous  motor  or  maniacal  parox- 
ysm ;  that  the  hysterical  insane  may  make  false  or 
pseudo-attempts  at  suicide.  To  illustrate  still  further, 
the  nurse  or  attendant  should  know  that,  for  various 
reasons,  accidents  are  likely  to  occur  among  cases  of 
paretic  dementia, — the  "  general  paretics,"  as  they  are 
commonly  termed  in  the  hospital.  These  patients,  al- 
though often  exceedingly  weak  and  frail  physically, 
owing  to  their  peculiar  mental  condition,  to  their  delu- 
sions of  strength  and  grandeur,  are  likely  to  be  de- 
monstrative and  pugnacious.  Frequently  they  have 
weak  hearts,  or  degenerated  livers  or  kidneys ;  often, 
as  in  locomotor  ataxia, — a  disease  closely  allied  in  pa- 
thology and  often  merging  into  it, — their  bones  are  very 
brittle ;  not  infrequently  they  have  lung  troubles.  If 
such  patients  are  handled  as  roughly  as  a  case  of  ordi- 
nary acute  mania,  the  consequences  may  be  serious. 
Collapse  has  been  known  to  come  on  almost  instantly 


100  THE  NURSING  AND   CARE   OF 

after  a  struggle  with  a  patient  of  this  kind,  and  in  badly- 
regulated  asylums  bones  are  frequently  broken ;  these 
accidents  occurring  even  when  no  cruelty  or  unusual 
violence  was  intended  or  attempted.  Attendants  should 
remember  that,  as  a  rule,  these  patients  are  not  ag 
strong  as  their  demonstrations  would  make  them  ap- 
pear. A  serious  accident,  resulting  in  the  death  of  the 
patient  and  the  subsequent  trial  of  the  attendant  on  a 
charge  of  manslaughter,  occurred  not  long  ago  in  one 
of  our  large  hospitals,  the  patient  being  a  general  par- 
etic with  pugnacious  and  aggressive  symptoms,  but 
with  advanced  mental  and  physical  degeneration.  It  is 
in  just  such  matters  as  flow  out  of  considerations  of  this 
kind  that  attendants  require  to  be  informed ;  they  need 
that  kind  of  knowledge  of  mental  disease  which  will 
enable  them  to  discriminate  in  their  management  of 
patients  of  different  classes.  What  is  known  as  hsema- 
toma  auris,  or  the  "insane  ear,"  is  not  infrequently 
present  in  general  paretics,  and  is  another  evidence  of 
degeneration.  The  external  ear  becomes  enormously 
swollen,  as  the  the  result  either  of  transudations  or  ex- 
travasations. Some  have  thought  that  all  cases  of  this 
kind  were  due  to  injury,  to  falls,  or  to  blows.  The 
truth  probably  is  that  neither  cases  of  hsematoma  auris, 
or  the  frequently-occurring  fractured  ribs  among  the 
insane,  are  always  or  oft'^n  due  to  cruel  treatment ;  but 
that,  in  handling  such  patients  without  due  care  or  con- 
sideration, slight  inj^'iries  produce  these  affections  to 
which  the  patients  are  predisposed,  and  which  might 
have  occurred  spontaneously  if  the  injuries  had  not 
been  inflicted. 


THE  NERVOUS  AND    THE  INSANE.  101 

It  is  sometimes  said  that  attendants  should  be  encour- 
aged to  take  a  scientific  interest  in  their  patients. 
Properly  understood,  this  assertion  is  true.  I  do  not 
think  that  it  will  be  of  any  service  to  the  unfortunate 
patient  for  the  attendant  to  become  a  sciolist  in  psychi- 
atry,— that  is,  to  have  a  smattering  of  knowledge  of 
anatomy,  physiology,  and  pathology  of  insanity  to  pa- 
rade on  occasions  or  make  use  of  improperly  in  behalf 
of  the  patient ;  but  the  kind  of  scientific  knowledge  which 
attendants  should  have  in  order  to  manage  the  insane 
for  their  best  interests  is  that  which  comes  from  a  study 
of  the  mental,  physical,  and  other  qualities  of  their 
patients,  and  of  the  details  of  the  best  methods  of 
handling  them  mentally,  physically,  and  otherwise. 
They  should  study  their  patients ;  they  should  learn 
what  gives  them  pleasure ;  what,  in  cases  of  melancholia, 
will  best  serve  to  draw  them  out  of  the  mental  shell 
into  which  they  have  retired  ;  in  cases  of  mania  what 
will  best  answer  to  soothe  and  calm  their  stormy  minds ; 
what,  in  cases  of  fixed  and  limited  delusions,  will  best 
divert  them  from  the  unhealthy  channels  into  which 
their  thoughts  are  directed. 

Nurses  and  attendants  should  have  sufficient  knowl- 
edge of  what  is  meant  by  delusions,  hallucinations, 
illusions,  etc.,  to  enable  them  to  understand  the  mental 
condition  of  the  patient,  for  certain  practical  purposes 
which  come  within  their  own  province.  Not  a  few  in- 
sane have  delusions  which  they  for  a  time  or  altogether 
suppress,  or  which  are  not  freely  or  openly  expressed. 
The  existence  of  such  delusions  in  most  cases  is,  in- 
deed must  be,  known  to  the  physician  who  has  the 


102  THE  NURSING   AND    CARE   OF 

patient  in  charge,  and  the  nurse  or  attendant  should  be 
promptly  informed,  in  order  not  only  to  guard  against 
special  dangers  which  may  arise  out  of  the  delusions, 
but  also  to  be  better  able  to  manage  the  unfortunate 
patient  without  offence  or  injury.  Thus,  an  attendant 
who  knows  that  the  patient  has  delusions  which  may 
lead  to  mutilation,  will  be  on  guard  against  the  occur- 
rence of  mutilation.  In  one  case  under  my  care  the 
patient^s  delusions  sometimes  took  the  form  that  it  was 
his  duty  to  destroy  his  eyes  because  they  had  offended, 
and  he  almost  succeeded  in  accomplishing  this  insane 
purpose  before  a  new  attendant  had  become  properly 
informed  as  to  the  delusion. 

Under  the  influence  of  peculiar  delusions  mutilations 
of  a  most  extraordinary  character  are  sometimes  per- 
formed, and  attendants  should  always  be  upon  the  alert. 
To  no  one  as  much  as  to  the  insane  does  the  old  saying 
so  fully  apply,  that  it  is  the  unexpected  that  always 
happens.  After  seemingly  almost  every  avenue  for  the 
commission  of  suicide  or  self- mutilation  has  been  closed, 
some  new  device  will  be  put  in  action,  and  perhaps 
successfully.  I  recall  one  instance  of  a  patient  in  a 
large  hospital  who  was  noticed  speaking  in  a  mum- 
bling manner.  He  was  at  first  passed  by,  but  on  second 
thought,  was  questioned,  and  on  refusing  to  open  his 
mouth  it  was  opened  forcibly,  and  it  was  found  that 
he  had  tied  his  tongue  with  a  cord,  which  had 
caused  it  to  be  much  swollen,  and  would  probably  in  a 
short  time  have  brought  about  sloughing  and  possibly 
fatal  hemorrhage.  In  this  case  the  act  was  performed 
in  all  probability  under  the  influence  of  a  delusion  that 


THE  NERVOUS  AND    THE  INSANE.  103 

his  tongue  was  an  unruly  member.  Although  not 
under  my  charge  at  the  time  of  the  occurrence,  this  man 
had  been  a  patient  of  mine,  and  one  of  his  delusions 
was  with  reference  to  his  tongue  or  speech. 

The  tendency  of  some  patients  to  secrete  and  swallow 
foreign  bodies  should  be  guarded  against. 

It  is  well  that  attendants  should  know  not  only  that 
the  sane  sometimes  simulate  insanity,  but  that  the  in- 
sane also  may  simulate  insanity,  giving  a  curious 
combination  of  a  real  and  a  feigned  disease  which 
is  sufficient  to  baffle  a  skilful  expert.  It  is  well 
that  nurses  and  attendants  should  appreciate  this,  be- 
cause it  has  happened  to  me,  as  well  as  to  other  physi- 
cians who  are  concerned  with  the  care  and  treatment  of 
the  insane,  that  attendants,  otherwise  faithful  and  suit- 
able for  the  work,  become  disturbed  as  to  the  existence 
of  insanity  in  the  patients  whom  they  discover  to  be 
shamming  in  some  particulars.  Tbey  discover  some 
deception,  and  with  their  little  knowledge  begin  to  think 
that  they  have  solved  the  problem  of  the  case  better 
than  the  doctor  himself. 

Still  another  similar  point,  which  it  is  well,  perhaps, 
that  attendants  should  know,  is  that  among  the  really 
insane  hysteria  in  some  form  is  often  present.  We  have 
not  only  a  form  of  insanity  which  is  called  hysterical, 
but  hysteria  in  many  forms  manifests  itself  among  the 
insane  of  different  classes.  I  am  led  to  remarks  like 
these  for  practical  reasons  which  have  grown  out  of 
experience.  I  have  had  a  faithful  nurse  come  to  me 
and  say  that  a  patient  was  hysterical,  and  only  wished 
to  create  a  sensation ;  that  she  did  not  believe  that  the 


104  THE  NURSING  AND   CARE  OF 

patient  would  hurt  herself;  and  such  statements  may 
have  had  some  foundation  in  truth :  but  in  just  such  a 
case  as  this,  also,  I  have  known,  within  twenty-four 
hours  of  the  time  at  which  the  statement  was  made,  the 
patient  nearly  to  succeed  in  committing  suicide  in  a 
way  that  left  no  doubt  for  a  moment  even  in  the  mind 
of  the  skeptical  nurse.  A  nurse  should  not  have  ar 
opinion  which  she  puts  in  practice  to  the  possible 
danger  or  detriment  of  patient  or  physician.  In  the 
long  run,  she  will  be  safest  to  refer  all  doubts  to  the 
physician,  rather  than  to  act  upon  them  herself. 

Later  I  shall  speak  of  the  importance  of  cleanliness 
on  the  part  of  attendants,  and  also  of  the  close  at- 
tention which  they  should  pay  to  cleanliness  on  the 
part  of  patients.  Not  only  should  cleanliness  of  body 
be  attended  to  as  a  matter  of  great  importance,  but 
cleanness  of  speech  and  of  heart  are  essentials  for  nurses 
and  attendants  upon  the  insane.  A  vulgar,  profane,  or 
immoral  person  has  no  right  to  be  in  charge  of  an  insane 
patient.  Opportunities  for  evil  and  for  injury  are  great 
and  should  be  guarded  against  by  carefully  selecting 
attendants  of  high  moral  tone. 

If  I  were  to  be  asked  who  make  the  best  attendants, 
E  should  say  young  men  or  women,  not  necessarily 
overlearned  in  medicine,  but  bright,  intelligent,  sym- 
pathetic, and  sensible  persons.  At  one  of  the  large 
asylums,  in  answer  to  my  inquiries,  I  was  told  that  on 
the  women's  side  young,  healthy  Irish  girls,  on  the 
whole^  made  their  best  attendants,  for  the  reason  that, 
as  a  rule,  they  were  strong,  had  good  animal  spirits, 
were  quick,  and  at  the  same  time  were  kind-hearted. 


THE  NERVOUS   AND   THE  INSANE.  105 

One  defect  serious  in  character,  however,  was  a  tendency 
not  always  to  adhere  to  the  truth  in  their  statements. 
A  good  nurse  or  attendant  for  the  insane  should  be 
firm  and  yet  forbearing,  quick  and  yet  not  hasty, 
courageous  and  yet  not  aggressive,  should  have  tact 
and  yet  not  be  deceitful.  It  has  often  been  observed 
in  large  institutions  for  the  insane  that  the  coming 
of  a  new  nurse  or  set  of  nurses  will  change  for 
a  time  the  conduct  and  character  of  a  whole  ward. 
Order  will  give  place  to  confusion  and  quietness  to 
discord.  A  nurse  who  is  fussy  and  too  demonstrative 
is,  above  all,  a  nuisance,  particularly  in  public  institu- 
tions. Nurses  should  avoid  deceiving  or  lying  to  the 
patients  under  their  charge.  Just  as  in  the  examination 
of  the  insane  an  occasion  may  arise  when  a  doctor  will 
be  justified  in  resorting  to  stratagem  or  even  to  deception, 
so  it  is  possible  that  a  nurse  or  attendant  in  some  grave 
emergency  or  peculiar  position  may  be  justified  in  tem- 
porarily deceiving  the  patient.  Such  occasions  are, 
however,  exceedingly  rare,  and  deception  should  never 
be  practised  when  it  is  in  any  way  possible  to  avoid  it. 
Most  insane  patients,  unless  they  be  dements,  are  capa- 
ble of  recognizing  deceit  and  dissimulation  in  others. 
The  tendency  of  the  insane  mind  itself  is  often  to  deceit 
and  dissimulation,  and  a  part  of  the  moral  or  psychical 
treatment  of  the  insane  should  be  the  enforcement  by  ex- 
ample of  physicians  and  nurses  of  good  moral  principle. 
Promises  which  cannot  be  kept  should  not  be  made. 

The  duties  of  a  faithful  nurse  or  attendant  upon  the 
insane  are,  as  a  rule,  arduous  and  wearing.  Sometimes 
a  nurse  may  be  put  in  charge  of  a  private  case,  one  of 


106  THE  NURSING  AND   CARE  OF 

dementia  or  mild  melancholia  for  instance,  which  will 
give  comparatively  little  trouble ;  but,  on  the  whole, 
cases  of  insanity  require  great  care  and  attention,  and 
to  be  in  charge  of  them  is  not  to  hold  a  sinecure.  In 
one  of  the  large  state  hospitals,  with  which  I  was 
formerly  connected  as  consultant,  the  best  and  strongest 
attendants,  after  a  year  of  faithful  service,  usually 
showed  marked  signs  of  physical  and  mental  wear. 
The  amount  of  service  required  by  the  regulations  of 
some  of  the  large  asylums  is,  I  think,  too  great,  while, 
as  a  rule,  the  compensation  is  far  too  small. 

The  nursing  and  care  of  the  insane  in  private  practice 
is  a  matter  of  grave  importance  and  one  which  requires 
some  special  points  of  consideration.  If  sufficient  means 
are  at  hand,  some  forms  of  insanity  can  be  as  well  or 
even  better  treated  at  their  own  homes  or  in  private 
houses  than  in  hospitals  or  asylums,  either  private  or 
public.  Patients  suffering  from  some  forms  of  mental 
disorder  are  comparatively  easy  to  manage  at  their  own 
homes.  Most  of  them,  however,  present  peculiar  diffi- 
culties, which  call  for  particular  mention  and  attention. 
Among  the  cases  most  likely  to  be  treated  with  success  at 
home  with  ultimate  chances  of  recovery  are  mild  melan- 
cholia, common  acute  mania,  when  nottoo  severe  in  char- 
acter, and  some  forms  of  hysterical  insanity.  Some  other 
forms  of  insanity,  such  as  senile  and  secondary  de- 
mentia, idiocy,  and  imbecility  of  various  grades,  may 
be  cared  for  at  home,  as  a  rule,  without  danger,  although 
in  such  cases  nothing  is  to  be  hoped  for  so  far  as  cure 
is  concerned.  The  effort  should  never  be  made  to  treat 
patients  at  home  or  in  private  houses  if  such  patients 


THE  NERVOUS  AND   THE  INSANE.  107 

require  constant  watching,  unless  the  friends  or  rela- 
tives of  the  patient  are  fully  able  to  employ  faithful 
attendants.  The  physician  is  often  asked  whether  such 
and  such  members  of  a  family  cannot,  as  well  as  not, 
look  after  the  patient.  As  a  rule,  but  not  one  without 
exceptions,  it  is  running  considerable  risk  to  allow  a 
patient  who  is  dangerous  to  himself  or  others  to  be 
attended  solely  by  members  of  his  family.  It  certainly 
cannot  be  done  without  great  risk  if  those  who  are 
supposed  to  have  charge  of  the  patient  have  other  duties 
which  claim  their  attention.  When  the  patients  are  so 
situated  financially  that  attendants  cannot  be  hired,  or 
that  members  of  the  family  or  friends  cannot  give  them 
exclusive  attention,  it  is  far  better  to  resort  to  hospital 
or  asylum  care. 

It  will  frequently  happen  in  the  private  or  home 
care  of  the  insane  that  two  attendants  are  put  in  charge 
of  a  patient ;  occasionally  the  number  will  even  be 
greater.  Unless  the  case  is  such  that  one  attendant 
is  required  to  be  in  charge  absolutely  for  a  certain 
number  of  hours  and  the  other  for  a  like  time,  the 
physician  finds  it  desirable  to  have  one  in  chief 
authority.  He  puts  one  nurse  in  charge,  making  him 
or  her  especially  responsible,  and  requiring  the  other, 
when  necessary,  to  act  under  instructions.  Occasions 
frequently  arise,  particularly  in  the  care  of  the 
violent  or  suicidal  insane,  when  there  is  necessity 
for  prompt  and  decided  action, — such  action  as 
can  be  taken  and  directed  by  one  clear  head.  In 
such  a  case  it  should  be  understood  that  the  re- 
quests or  even  directions  of  the  chief  nurse  shall  be 


108  THE  NURSING  AND   CARE  OF 

coincided  with  or  obeyed  by  the  other.  I  have  known 
a  patient  to  be  injured,  so  far  as  efforts  to  control  him 
were  concerned,  by  the  petty  jealousies  which  have  arisen 
between  the  nurses  in  attendance.  It  has  seemed  to  me 
— possibly  I  may  be  mistaken  with  reference  to  this — 
that  these  are  more  likely  to  arise  among  women  than 
among  men.  No  appearance  of  discord  or  disagree- 
ment between  attendants  should  ever  be  shown  before 
a  patient.  Such  an  exhibition  may  be  destructive 
of  all  efforts  to  control  a  patient  for  his  or  her  own 
good. 

Much  of  the  instruction  which  is  given  to  resident 
physicians,  nurses,  or  attendants  in  charge  of  the 
insane  must  necessarily  have  reference  to  the  habits, 
conduct,  and  peculiarities  both  of  patients  and  those 
in  charge ;  and  it  is  for  this  reason  that  I  am  compelled 
to  devote  so  much  space  to  the  consideration  of  ques- 
tions of  this  kind. 

Attendants  should  never  foolishly  ridicule  patients. 
While  sometimes  harmless  amusement  may  be  derived 
from  listening  to  the  vagaries  of  the  insane  whose  de- 
lusions or  notions  are  of  a  pleasant  or  joyous  type,  on 
the  other  hand  patients  should  never  either  be  encour- 
aged in  their  delusions,  or  ridiculed  because  of  them  or 
of  anything  else  which  is  the  result  of  their  impaired 
mental  condition. 

In  institutions,  nurses  and  attendants  should  be  care- 
ful not  to  indulge  in  favoritism,  and  not  to  single  out 
any  patients  for  special  antipathy.  Probably  nowhere 
in  the  world  can  so  many  annoying  and  gener- 
ally  disagreeable   individuals  be   found   together   as 


THE  NERVOUS  AND    THE  INSANE.  109 

in  a  large  insane  hospital.  It  follows  as  a  matter  of 
course  from  their  mental  condition  that  this  should  be 
so;  but  the  highest  type  of  nurse  or  attendant  is 
one  who,  appreciating  all  this,  is  able  to  pursue  a 
straight-forward,  honorable  course  in  caring  for  every 
patient. 

All  disputes  and  differences  of  opinion  should  be 
referred  to  the  physician.  Forbearance  under  temp- 
tation, the  ability  to  suppress  envy,  jealousy,  or  self 
in  any  way,  the  willingness  to  do  all  things  and  forego 
all  things  for  the  sake  of  the  patient,  are  among  the  most 
needed  qualities  of  a  good  attendant.  The  nurse  who 
is  given  chief  authority  in  the  care  of  a  private  patient 
should  not  be  officious  or  exacting,  but  should  make  it 
her  special  aim  to  see  that  the  directions  of  the  physi- 
cian are  implicitly  carried  out ;  should  report  to  the 
physician  in  charge  everything  disagreeable,  and  all 
derelictions. 

In  most  cases  it  is  weU  for  the  chief  nurse  to  keep 
a  careful  record  of  the  details  of  treatment  and  also  of 
the  meals,  amount  of  sleep,  exercise,  kind  of  occupation 
or  amusement,  and  in  particular  instances  the  individ- 
ual peculiarities  of  certain  patients.  A  systematic 
method  of  recording  the  time  of  administration  of 
medicines,  and  so  on,  is  advisable.  Printed  blanks  are 
used  in  some  institutions,  and  if  carefully  prepared 
may  be  of  great  service. 

Attendants  upon  the  insane  should  not  become  to 
any  extent  routinists.  They  should  not  become  so  fa- 
miliar with  their  patients  as  to  forget  many  of  the  little 
things  that  they  may  need.     The  insane  often  suffer  for 


110  THE  NURSING  AND   CARE  OF 

want  of  little  things, — for  things  of  which  they  need 
not  be  deprived  and  of  which  no  one  cares  to  de- 
prive them,  but  which  they  often  do  not  get  because 
of  carelessness  or  thoughtlessness.  They  often  suf- 
fer, for  example,  for  water.  I  have  been  told  by  an 
intelligent  lady  that  she  drank  her  own  urine,  not 
because  of  a  delusion,  but  because  of  absolutely  un- 
controllable thirst  which  was  not  properly  gratified. 
Acts  of  this  kind  are  most  frequently,  no  doubt,  due 
to  delusions. 

Sometimes  the  insane  do  not  receive  sufficient  food. 
In  some  forms  of  insanity,  owing  to  the  tremendous 
waste  of  tissue  which  takes  place  in  consequence  of  the 
wearing  mental  disorder,  large  quantities  of  food  are 
called  for.  Of  course,  arranging  the  amount  of  food 
is  a  matter  for  the  physician,  but  nurses  should  see 
to  it  that  the  food  is  given  as  directed.  As  a  rule, 
insane  patients  eat  too  much  rather  than  too  little,  and 
this,  of  course,  must  also  be  guarded  against. 

The  protection  of  the  insane  from  the  commission  of 
suicide  is  a  most  important  duty  upon  the  part  of  an 
attendant.  It  is  strange  in  how  many  ways  and  with 
how  much  shrewdness  the  insane  will  accomplish  this 
dire  purpose  if  intelligent  vigilance  is  not  exercised. 
Suicides  by  the  insane,  like  suicides  by  the  sane,  are  of 
the  most  diverse  character,  as  far  as  method  of 
performance  is  concerned.  The  attempt  to  hang  is 
common.  An  insane  patient  has  been  known  to  hang 
herself  by  a  shoe-string  or  an  apron-string  to  the  door- 
knob of  a  room,  or  the  bed  cords,  the  sheets,  clothing, 
etc.,  have  been  employed.     To  drown  themselves,  pa- 


THE  NERVOUS  AND    THE  INSANE.  HI 

tient3  do  not  require  rivers  nor  even  bath-tubs.  They 
have  been  known  successfully  to  accomplish  this  pur- 
pose by  thrusting  the  head  into  a  pail  or  even  into  a 
basin  of  water.  Sometimes  objects  are  thrust  by  the 
patients  into  their  own  mouths  to  choke  themselves  or 
strangle  themselves  to  death.  Sometimes  they  cut  them- 
selves with  glass  which  has  obtained  by  breaking  win- 
dows. 

Knives,  scissors,  razors,  and  all  forms  of  cutting 
instruments  should  be  carefully  kept  out  of  the  way  of 
patients  who  are  likely  to  injure  themselves  by  such 
means.  The  greatest  possible  care  should  be  taken  by 
nurses  or  attendants  with  reference  to  the  custody  of 
medicines  administered  to  the  patients.  Here,  again, 
it  is  advisable  that  they  should  have  some  little  prac- 
tical instruction  as  to  the  strength  and  danger  of  the 
most  potent  remedies  which  are  intrusted  to  their  care 
for  administration.  They  cannot  be  expected  to  have 
exact  and  profound  knowledge  as  to  the  physiological 
properties,  sources,  etc.,  of  morphia,  conium,  hydrobro- 
mate  of  hyoscine,  atropia,  duboisia,  digitalis,  chloral, 
bromides,  cannabis  indica,  and  the  long  list  of  powerful 
medical  implements  which  are  put  into  their  hands; 
but  they  should  know  that  these  drugs  are  dangerous 
and  deadly  poison  in  more  than  a  proper  dose.  They 
should  keep  them  out  of  the  reach  of  patients  in  inter- 
vals between  the  times  of  giving  the  particular  doses 
ordered;  where  possible,  they  should  be  kept  in  an 
adjoining  room,  and  always  under  lock  and  key  and 
entirely  out  of  reach.  While,  however,  in  the  case  of 
patients  suicidally  inclined  the  means  of  suicide  should 


112  THE  NURSING  AND   CARE  OF 

be  kept  or  put  out  of  reach,  this  should  not  be  done  in 
a  fussy  or  demonstrative  waj.  Such  things  should,  as 
far  as  possible,  not  attract  the  attention  of  patients. 

Comparatively  little  restraint  of  a  mechanical  kind 
is  now  used  in  the  care  of  the  insane.  In  some  cases, 
however,  rare  though  they  be,  it  may  be  absolutely 
necessary  to  protect  patients  from  mutilation  or  suicide. 
Mechanical  restraint  should  not  be  applied  by  a  nurse 
or  attendant  except  by  the  direction  of  the  physician  ; 
and,  if  it  is  used,  care  should  be  taken  that  no  evil 
consequences  result.  Not  long  since,  in  a  large  hospital 
for  the  insane,  a  patient  who  had  been  restrained  by 
straps  in  a  bed,  and  was  supposed  by  the  attendant  to 
be  sleeping,  so  dragged  himself  down  over  the  side  of 
the  bed  as  actually  to  cause  his  death  by  means  of  the 
straps  with  which  he  was  supposed  to  be  restrained 
and  protected. 

When  it  becomes  absolutely  necessary  for  a  nurse  or 
attendant  to  take  hold  of  an  insane  patient,  care  should 
be  exercised  as  to  the  manner  in  which  this  is  done. 
Usually  patients  requiring  to  be  taken  hold  of  are  vio- 
lent,— cases  of  mania,  homicidal  monomania,  of  agi- 
tated melancholia,  and  the  like.  When  two  attendants 
are  present  it  is  well,  while  one  secures  the  attention  of 
the  patient  by  demonstrations  in  front,  for  the  other  to 
get  behind  him  and  either  throw  the  arms  around  him 
or  seize  both  arms  carefully  but  firmly  above  the  elbows. 
Whatever  plan  of  seizing  patients  is  adopted,  care 
should  be  taken  not  to  inflict  injury.  It  is  only 
in  self-defence,  that  is,  in  defence  of  life  or  limb  in 
an  emergency,  that  an  attendant  is  ever  justified  in 


THE  NERVOUS  AND   THE  INSANE.  113 

striking  or  roughly  handling  a  patient.  A  patient,  of 
course,  may  kick  backwards  when  seized  from  behind ; 
but  the  attendant  by  slipping  his  feet  and  legs  as  far  as 
possible  to  one  side  can  usually  avoid  being  injured  in 
this  way. 

When  applications  of  heat  or  cold  are  made  to  the 
insane,  special  attention  should  be  paid  to  them.  In 
some  forms  of  insanity  insensibility  of  the  skin 
is  present,  and  patients  would  in  these  cases  allow 
blisters  or  mustard-plasters  or  stupes,  or  fomenta- 
tions or  any  form  of  hot  or  counter-irritating  appli- 
cations to  remain  until  serious  blistering  occurred. 
On  the  other  hand,  the  insane  are  sometimes  more  im- 
patient of  such  applications  than  the  sane  ;  in  any  case, 
special  attention  should  be  given  to  the  matter  by  the 
attendant.  The  same  remarks  apply  to  the  use  of  cold 
water  or  ice. 

All  physicians  who  are  engaged  in  the  care  and  treat- 
ment of  the  insane  now  recognize  the  importance  of 
occupation,  amusement,  and  educational  training  as 
therapeutic  resources.  To  attendants,  the  carrying  out 
of  plans  of  occupation,  amusement,  and  teaching  must 
be  largely  intrusted.  In  institutions,  of  course,  methods 
and  measures  for  the  promotion  of  these  objects  will 
be  carefully  planned  and  regulated,  if  the  institutions 
are  up  to  the  times  in  their  management.  The  curse  of 
many  hospitals  and  asylums  for  the  insane  has  been 
idleness.  It  is  not  within  my  design  in  the  present 
chapter  to  go  into  a  consideration  of  the  methods  and 
forms  of  employment,  amusement,  and  instruction,  but 

simply  to  give  a  few  hints  and  suggestions  as  to  the 

8 


114  THE  NURSING  AND   CARE   OF 

manner  of  carrying  out  the  details,  so  far  as  such  de- 
tails are  intrusted  to  nurses  and  attendants. 

In  the  first  place,  patients  should  be  encouraged,  and 
in  some  cases  be  compelled,  to  do  that  work  which  is 
called  for  in  their  own  personal  care.  They  can  be 
encouraged,  or  made,  to  take  care  of  themselves,  so  far 
as  cleanliness  is  concerned.  Female  patients  should  be 
made,  when  possible,  to  care  for  their  own  rooms,  beds, 
etc.  Attention  should  be  paid,  of  course,  particularly 
in  private  practice,  to  the  question  of  the  usual  customs 
and  habits  of  the  patient. 

No  matter  what  may  be  the  work  at  which  an  insane 
patient  is  engaged,  whether  sewing,  knitting,  quilting, 
ironing,  or  book-keeping ;  or,  if  men,  gardening, 
ploughing,  brush-making,  chair-making,  or  printing, 
a  duty  that  will  be  incumbent  upon  the  attend- 
ant more  often  than  upon  the  physician  will  be 
to  see  that  the  patient  does  not  overwork  himself. 
While  the  tendency  will  be  to  do  too  little,  in  some  cases 
insane  patients  will  certainly  try  to  do  too  much.  This 
is  particularly  true  in  some  forms  of  insanity  attended 
with  excitement,  some  varieties  of  mania,  for  instance, 
in  which  the  patient  tends  to  do  everything  to  excess. 
Again,  a  patient  may  overwork  as  the  result  of  some 
special  delusion.  Thus,  Dr.  Massey  ^  speaks  of  the  case 
of  a  lady  in  good  circumstances  who,  having  been  left 
with  a  family  to  support,  resorted  to  dress-making,  but 
became  insane  and  was  sent  to  an  asylum,  where  she  was 
induced  to  go  to  work  in  the  sewing-room.     The  result 

^Penn  Monthly,  November,  1879 


THE  NERVOUS  AND   TEE  INSANE.  115 

waa  the  production  of  a  new  delusion :  she  believed 
she  was  in  charge  of  the  sewing-room  with  large  wages, 
and  made  great  exertions  in  consequence.  Becoming 
troublesome,  she  was  transferred  to  the  laundry,  where 
the  same  thing  was  re-enacted ;  this  resulting  at  last 
in  complete  exhaustion  and  confinement  to  bed. 

Exercise  is  of  the  utmost  importance  to  many  insane 
patients.  In  suitable  weather,  out-of-door  exercise 
should  be  provided  for ;  and  here,  again,  the  careful 
attendant  will  guard  against  under-exercising  on  the 
one  hand,  or  over-exercising  on  the  other. 

Torpor  of  the  bowels  and  obstinate  constipation  are 
of  such  frequent  occurrence  among  the  insane  that  both 
resident  physicians  and  attendants  should  have  their 
attention  particularly  directed  to  these  conditions.  In 
melancholia,  the  bowels  may  remain  constipated  for 
days  and  even  weeks  if  the  patients  are  neglected. 
A  large  number  of  insane  patients  in  asylums,  par- 
ticularly many  of  the  cases  of  dementia,  are  troubled 
with  involuntary  evacuations  from  thebowels  or  bladder, 
particularly  at  night-  In  private  patients  the  same 
difficulty  may  be  encountered,  and  it  is  well  for  physi- 
cians and  nurses  to  have  some  plan  of  meeting  the 
difficulty.  In  one  large  hospital  the  plan  adopted  is  a 
very  sensible  one.  The  physician  in  charge  has  a  list 
of  all  patients  who  are  troubled  in  this  way,  and  in  the 
evening  before  retiring  injections  of  warm  water  are 
given ;  the  lower  bowel  is  thus  emptied,  and  the  proba- 
bility is  that  the  patients  will  not  soil  their  beds.  In 
some  cases,  in  addition  to  emptying  the  bowels,  the 
bladder  may  have  to  be  relieved  by  the  catheter. 


116  THE  NURSING  AND   CARE  OF 

Cleanliness  on  the  part  of  a  nurse  or  attendant  upon 
the  insane  is  of  the  utmost  importance.  It  is  impor- 
tant not  only  for  itself,  but  for  the  example  which  it 
sets  to  the  patient.  The  insane  may  be  made  less 
cleanly  than  their  mental  affliction  would  lead  them 
to  be  by  the  example  of  others ;  on  the  other  hand, 
they  may  become  cleanly  in  habit  simply  from  an 
example  steadily  set. 

The  bathing  of  insane  patients  is  a  matter  of  im- 
portance, both  from  the  point  of  view  of  cleanliness 
and  as  a  therapeutic  agent,  and  attendants  should  be 
thoroughly  instructed  in  reference  to  this  matter. 
They  should  also  have  a  lively  appreciation  of  the 
dangers  which  may  attend  bathing.  A  terrible  acci- 
dent recently  occurred  in  one  of  the  larger  asylums 
of  a  neighboring  state,  the  patient  having  been  liter- 
ally parboiled  by  an  attendant.  As  many  insane  pa- 
tients make  a  great  fuss  and  offer  much  resistance  to 
bathing  at  all  times,  a  careless  or  impatient  attendant 
might  fail  to  listen  or  assure  himself  of  the  conditions. 
Kigid  rules  are  prescribed  in  all  well-regulated  public 
institutions.  The  rules  for  bathing  which  are  in  force 
at  the  State  Hospital  for  the  Insane,  Norristown,  Penn- 
sylvania, so  fully  express  what  should  be  said  with 
reference  to  this  matter  that  I  will  quote  the  most  im- 
portant of  them : 

The  ward  captains  will  personally  supervise  the  Dathing  of  pa- 
tients, which  shall  not  be  conducted  during  their  absence  without 
permission. 

Every  patient  .d  to  be  bathed  immediately  after  admission,  and 
once  a  week  afterwards,  unless  excused  by  medical  order.    Should 


THE  NERVOUS  AND    THE  INSANE.  117 

there  be  the  least  doubt  as  to  the  advisability  of  bathing  any  pa- 
tient, owing  to  sickness,  feebleness,  or  excitement,  the  matter 
should  be  immediately  reported  to  the  general  officer. 

To  provide  against  catching  cold,  the  captains  will  see  that  the 
bath-  and  dressing-rooms  are  sufficiently  warmed  at  bathing  times, 
otherwise  to  postpone  bathing  until  the  rooms  are  heated. 

Any  marks,  bruises,  wounds,  sores,  pain,  or  evidence  of  dis 
ease  complained  of  by  the  patient,  or  noticed  during  any  of  the 
bathing  operations,  must  be  immediately  reported  to  the  physician. 

During  the  use  of  the  bath,  the  room  is  never  to  be  left  by  the 
attendant,  except  by  special  permission  of  the  resident  physician. 
When  the  room  is  not  in  use  the  door  must  be  kept  locked. 

Before  putting  the  patient  into  the  bath  observe  that  the  water 
is  of  proper  temperature.  It  should  not  be  less  than  88°  nor 
above  98°. 

!Never  turn  on  the  hot  water  when  the  patient  is  in  the  tub. 

In  the  bath  the  body  of  the  patient  is  to  be  well  cleansed  with 
soap ;  and  in  washing  the  hair  be  careful  that  no  soap  gets  into 
the  patient's  eyes.  After  leaving  the  water,  especial  care  must 
be  taken  to  thoroughly  dry  the  patients,  and  clothe  them  as  rapidly 
as  possible.     A  separate  towel  must  be  provided  for  every  one. 

Under  no  pretence  whatever  is  a  patient's  head  to  be  put  under 
water. 

An  attendant  must  not  attempt  under  any  circumstances  to 
bathe  a  struggling  patient  alone. 

Cold  baths  must  never  be  given. 

Neither  before  nor  after  the  bath  will  patients  be  allowed  to 
stand  about  unclothed. 

The  keys  are  never  to  be  left  on  the  bath-taps,  nor  are  they  to 
be  used  by  the  patients. 

I  will  next  speak  briefly  of  the  methods  of  feeding 
patients  forcibly.  I  do  this  because  this  book  is 
intended  for  the  instruction  of  resident  physicians,  as 
well  as  of  nurses  and  attendants.  I  do  not  believe  that 
nurses  or  attendants  should  be  allowed  to  have  the 
feeding  of  patients  in  this  manner  under  their  own 


118  THE  NURSING  AND    CARE   OF 

charge ;  but,  as  it  is  necessary  for  them  to  assist  in 
performing  this  work,  they  should  receive  instruction 
as  to  the  whole  process  in  order  that  they  may  be  better 
able  to  render  assistance  to  the  physician.  In  some 
institutions  head  nurses  have  been  allowed  to  admin- 
ister food  in  this  way ;  but  it  is  contrary  to  the  regu- 
lations of  all  the  institutions  for  the  insane  of  which 
I  have  knowledge  to  allow  this  to  be  done. 

Not  a  few  cases  of  insanity  require,  at  times,  to  be 
fed  by  force.  The  cases  in  which  such  treatment  is 
called  for  differ  somewhat.  In  melancholia  patients 
will  allow  themselves  to  run  down  rapidly  in  health,  or 
even  starve  to  death,  if  the  food  is  not  promptly  admin- 
istered by  artificial  means.  Sometimes  cases  of  mania 
will  refuse  to  take  food,  either  because  of  their  general 
excitement  and  combativeness  or  because  of  delusions. 
Paranoiacs  or  monomaniacs  refuse  food,  if  at  all,  because 
of  some  fixed  delusion.  A  patient  suffering  from  chronic 
alcoholic  insanity,  or  even  in  rare  instances  a  paretic  de- 
ment, may  refuse  food  because  of  a  delusion,  for  instance, 
that  food  is  being  poisoned  by  physicians,  attendants, 
or  others,  or  that  it  is  a  means  resorted  to  to  accomplish 
some  purpose  on  the  part  of  a  persecutor.  The  refusal 
of  food  by  a  patient  with  hysterical  insanity,  like  the  ap- 
parent attempts  at  suicide,  is  usually  simply  resorted 
to  for  the  purpose  of  exciting  sympathy.  In  most 
cases  these  patients  will  obtain  food  on  the  sly  if  pos- 
sible, but  sometimes  they  will  carry  on  the  deception 
sufficiently  long  to  injure  themselves,  if  the  attendants 
do  not  resort  to  active  interference. 

Various  plans  of  feeding  patients  by  force  have  been 


THE  NERVOUS  AND   THE  INSANE.  119 

recommended  at  different  times ;  two  of  these  are  now 
almost  universally  employed,  and  one  of  the  two, 
namely,  nasal  feeding,  is  now  coming  more  and  more 
into  general  use. 

The  three  methods  in  more  or  less  common  use  will 
be  described.  The  first  plan  is  that  of  holding  the  nos- 
trils closed  and  opening  the  mouth,  or  thus  compelling 
it  to  be  opened,  while  the  food  is  quickly  poured  into 
the  mouth,  and  the  patient  is  forced  to  swallow  it  in- 
stantaneously. A  certain  amount  of  danger  accompa- 
nies this  plan,  which,  by  the  way,  is  the  one  often  re- 
sorted to  in  the  case  of  recalcitrant  children.  If  any  one 
should  make  the  experiment  of  trying  to  swallow  liquids 
or  solids  while  the  nose  is  tightly  held,  so  that  no 
air  can  enter  through  it,  he  will  find  that  it  is  a 
very  difficult  or  almost  impossible  thing  to  accom- 
plish. The  fact  that  the  reason  an  individual,  whose 
nose  is  held,  opens  the  mouth  in  order  to  breathe 
shows  the  source  of  possible  danger,  which  is  that  the 
glottis  being  open  in  order  to  receive  air  into  the  lungs 
at  the  same  moment  that  food  is  hastily  thrust  into  the 
mouth,  some  of  the  food  is  very  likely  to  find  its  way 
into  the  windpipe  and  thus  choke  or  strangle,  or 
partially  choke  or  strangle,  the  patient.  This  method 
of  feeding  is  now  not  much  employed. 

Dr.  D.  Anderson  Moxey^  was  among  the  first  to  call 
attention  to  the  administration  of  food  and  medicine  by 
the  nose  when  they  could  not  be  given  by  the  mouth. 
He  resorted  to  this  method  in  cases  of  insanity,  in  in- 

*  The  Lancet. 


120  THE  NURSING  AND   CARE   OF 

flamed  and  ulcerated  sore  throat,  in  glossitis,  in  deep 
intoxication,  and  in  infancy,  where  nothing  could  be 
administered  by  the  mouth  or  retained  by  the  rectum. 
In  cases  of  insanity  he  fed  his  patients  without  the 
use  of  a  tube  by  simply  holding  a  small  wedgewood 
funnel  in  one  of  the  nostrils,  and  pouring  through  it 
the  liquid  or  semi-solid  nourishment.  He  describes 
his  method  with  insane  patients  as  follows  :  After  first 
trying  to  induce  the  patient  to  take  the  nourishment 
quietly  and  in  the  ordinary  way,  he  summoned  three 
attendants  at  least  (four  or  five,  if  they  could  be  had), 
and  laid  the  patient  down  on  his  back  as  quietly  as 
possible  on  a  low  couch  in  the  middle  of  the  room.  If 
there  were  only  three  attendants,  one  controlled  the  legs 
and  the  other  two  the  arms ;  if  a  fourth  was  present, 
he  attended  only  to  the  head,  which  was  held  between 
his  knees  as  the  attendant  sat  on  a  low  stool  at  the  top 
of  the  couch.  If  a  fifth  was  present,  he  assisted  in 
holding  down  the  legs.  In  this  way  the  patient  was 
completely  controlled,  and  sometimes  would  yield  and 
swallow  in  the  usual  way.  Then  introducing  the  end 
of  the  funnel  gently  into  one  of  the  nostrils,  he  poured 
the  liquid  slowly  into  it,  pausing  now  and  then  to  allow 
the  patient  to  take  a  deep  inspiration,  and  not  allowing 
the  food  to  accumulate  in  the  funnel.  A  determined 
patient  would  generally  be  able  to  sputter  a  little  of  ii 
out  of  his  mouth ;  when  such  was  the  case  he  poured 
the  contents  of  the  jug  faster  into  the  funnel,  and  some- 
times obstructed  the  other  nostril.  In  troublesome 
cases  a  medical  man  ought,  he  insisted,  invariably  to 
administer  the  draught  as   he  alone  could   properly 


THE  NERVOUS  AND    THE  INSANE.  121 

judge  of  the  extent  to  which  it  was  necessary  to  in- 
terrupt nasal  respiration.  Dr.  Moxey  never  found  any- 
serious  results  from  this  method  of  feeding.  I  have 
referred  to  these  observations  of  Dr.  Moxey  to  show 
the  perfect  feasibility  of  nasal  feeding,  and  one  of  the 
methods  of  holding  the  patient  by  which  it  can  even  be 
accomplished  without  the  aid  of  a  tube,  although  un- 
doubtedly the  use  of  the  tube  is  the  neater  and  better 
method. 

A  good  tube  for  feeding  by  the  nose  can  be  made  by 
attaching  a  soft  N^laton  catheter  to  a  long  piece  of 
drainage-tube  of  a  calibre  which  will  just  allow  the 
catheter  to  tightly  fit  into  it.  To  the  extremity  of  the 
drainage-tube  a  funnel  of  large  size  should  be  attached. 

In  nasal  feeding  some  of  the  difficulties  and  dangers 
which  are  met  with  should  be  borne  in  mind.  The 
number  of  patients  who  cannot  be  fed  by  the  nose  is 
very  small ;  occasionally,  however,  a  patient  is  found 
whom  it  seems  impossible  to  feed  in  this  way,  owing 
to  the  choking  and  strangling  produced.  This  may  be 
because  of  some  peculiar  anatomical  conformation,  or 
some  special  idiosyncrasy  on  the  part  of  the  patient. 
Such  a  patient  will  choke  or  strangle  with  nasal  feed- 
ing when  he  will  not  when  the  stomach-tube  is  resorted 
to.  If,  when  the  attempt  is  made  to  pass  the  well- 
oiled  tube  through  the  nostril,  resistance  is  encountered, 
and  if,  after  a  few  trials,  the  tube  cannot  be  made  to 
pass,  great  force  should  not  be  employed  by  the  oper- 
ator, but  the  tube  should  be  at  once  withdrawn  and 
the  eifort  should  be  made  to  pass  it  through  the  other 
nostril.     In  nearly  all  cases  where  special  resistance  is 


122  THE  NURSING  AND   CARE  OF 

offered  on  one  side  the  tube  will  pass  with  ease  upon 
the  other,  and  this,  in  most  instances,  is  because,  if 
hypertrophies  or  projections  exist  upon  one  side,  there 
will  be  upon  the  other  corresponding  or  compensating 
depressions  and  enlargements.  Sometimes,  but  rarely, 
the  mucous  membrane  is  exceedingly  irritable.  After 
the  nasal  tube  has  passed  through  the  nostrils  it  seems 
to  have  the  peculiar  tendency  in  some  cases  to  drop  into 
the  glottis,  the  patient  struggling  and  attempting  to 
scream  meanwhile.  Some  patients  will  spit  or  force 
the  tube  out  into  the  mouth,  and  attendants  can  some- 
times, through  the  mouth,  keep  the  tube,  which  has 
been  passed  through  the  nose,  in  position.  Occasionally 
the  nose  is  made  sore  by  the  use  of  the  tube,  but  this 
is  not  likely  to  occur  if  the  tube  is  always  perfectly 
clean  and  well  oiled.  If  it  is  of  the  proper  kind, — 
that  is,  a  soft  tube, — there  will  be  no  danger  of  injur- 
ing the  parts  by  breaking  or  perforating  the  mucous 
membrane.  Indeed,  one  of  the  advantages  of  the 
nasal  tube  over  the  form  of  stomach-tube  or  cesophageal- 
tube  which  is  commonly  employed  is  that  the  danger  of 
injury  by  perforation  or  abrasion  is  much  less.  The 
stomach-tube  must  be  a  little  larger  and  of  firmer  make, 
and  it  is  likely,  after  a  little  usage,  particularly  if 
not  looked  after  with  care,  to  become  stiff  and  hard. 
I  know  of  one  instance  in  which  the  oesophagus  was 
pierced  by  a  stomach-tube  in  the  hands  of  an  unskilful 
attendant.  In  using  the  nasal  tube,  care  should  al- 
ways be  exercised  to  see  that  at  least  fifteen  to  sixteen 
inches  of  the  tube  has  been  passed  before  beginning  the 
feeding.     This  will  make  it  certain  that  the  entrance 


THE  NERVOUS  AND    THE  INSANE.  123 

to  the  windpipe  has  been  passed.  Of  course,  care 
should  be  taken  to  observe  that  the  tube  has  not 
doubled  on  itself.  Dr.  Spitzka  speaks  of  the  method 
of  feeding  by  force  as  follows  : 

"  Whether  fed  with  the  funnel  or  the  stomach-pump, 
the  patient  should  sit  up ;  and  if  he  is  very  obstructive, 
a  restraining-chair  will  save  the  patient  much  needless 
muscular  exertion,  the  physician  much  trouble,  and 
diminish  the  chances  of  doing  an  injury.  In  case  the 
oesophageal  tube  is  passed  along  the  floor  of  the  nasal 
cavity,  it  is  apt  to  encounter  a  resistance  and  be  deflected 
forward  by  a  prominence  which  is  sometimes  very 
marked  on  the  posterior  pharyngeal  wall,  and  which 
corresponds  to  the  bodies  of  the  cervical  vertebrae.  Dr. 
Tuke  advises  throwing  the  head  of  the  patient  back  at 
the  moment  when  the  sound  approaches  the  posterior 
nares,  the  tube  having  previously  been  bent  a  little  so 
as  to  facilitate  its  downward  passage ;  then  at  the  mo- 
ment when  it  is  about  to  glide  down  into  the  oesophagus, 
when  there  is  a  risk  of  its  passing  into  the  larynx,  he 
advises  the  head  to  be  brought  forward  and  downward 
so  as  to  send  the  point  against  the  posterior  wall  of  the 
pharynx.  After  passing  the  upper  end  of  the  oesoph- 
agus, the  tube  is  usually  swallowed,  as  it  were,  and 
glides  down  without  any  further  difficulty  into  the 
stomach  through  the  action  of  the  constrictor  muscles."  ^ 

Whenever  a  patient  is  fed  forcibly,  care  should  be 
taken  to  have  ample   force  to  restrain  him  without 


*"  Insanity,  Its   Classification,    Diagnosis,   and   Treatment." 
By  E.  C.  Spitzka,  M.D. 


124  THE  NURSING  AND    CARE   OF 

a  vi  )lent  struggle.  The  sight  of  overwhelming  force 
will  have  a  good  moral  or  psychical  influence  over  the 
natient.  Three  persons  can  feed  a  patient  successfully, 
no  matter  how  great  the  inclination  to  resist,  if  these 
persons  are  skilful  and  have  sufficient  strength.  With 
less  than  three  persons  the  difficulty  will  be  very  great, 
and  in  some  cases  it  will  be  impossible  successfully  to- 
accomplish  the  purpose.  One  attendant  should  always 
be  charged  with  the  task  of  firmly  holding  the  head  in 
position ;  another  can  hold  the  arms  and  hands,  with 
the  body  thrown  over  the  limbs  of  the  patient,  who  be- 
fore this  is  attempted  should  be  well  enveloped  in  a 
blanket  or  sheet.  It  is  much  better,  however,  to  have 
two  attendants  hold  the  arms  and  legs. 

After  a  patient  has  been  fed,  the  tube  should  be 
always  promptly  cleansed.  Hot  water  cannot  be  used 
because  of  the  melting  of  the  india-rubber,  but  the  tube 
should  be  washed  by  allowing  cold  water  to  run  through 
and  over  it.  Negligent  attendants  are  likely  to  neglect 
this  matter. 

Whether  fed  by  the  mouth  and  oesophagus  or 
through  the  nose,  patients  in  rare  instances  learn  to 
vomit  or  regurgitate  the  food.  If  this  occurs,  it  is  a 
matter  for  a  physician  rather  than  for  a  nurse  or  at- 
tendant. It  has  been  found  that  the  administra- 
tion of  morphia  and  hyoscyamine  prior  to  the  time 
of  feeding  will  sometimes  prevent  the  patient  from  ex- 
ercising this  power.  Two  doses,  say  of  sulphate  of 
morphia  gr.  J  and  hyoscyamine  gr.  -^  to  -j^,  may  be 
given,  the  first  three  or  four  hours,  and  the  second 


THE  NERVOUS  AND    THE  INSANE.  125 

one-  hour  or  less  before  the  times  for  administering  the 
food. 

If  the  nasal  mucous  membrane  or  the  mucous  mem- 
brane of  the  throat  should  be  unusually  irritable,  resort 
may  be  had  to  a  weak  solution  of  the  hydrochlorate  of 
cocaine,  which  can  be  painted  over  them. 

The  administration  of  such  remedies  as  morphia, 
hyoscyamine,  and  the  bromides  will  also,  of  course,  in 
cases  of  insanity,  as  in  other  cases,  tend  to  diminish  the 
pharyngeal  reflex  and  thus  allow  of  the  use  of  forcible 
mechanical  feeding  with  less  trouble;  but  prescribing 
medicines  is  the  duty  of  the  physician,  and  therefore 
little  is  said  here  about  such  matters. 

One  advantage  in  using  the  stomach-tube  through 
the  mouth  is  that  when  the  latter  is  kept  well  opened 
by  means  of  a  bandage  or  a  screw- wedge,  the  finger  of 
the  physician  or  attendant  can  be  used  to  guide  the  tube 
past  the  epiglottis  into  the  oesophagus,  and  thus  pre- 
vent any  danger  no  matter  how  much  the  patient  may 
struggle  or  use  his  breathing  apparatus. 

No  matter  how  a  patient  is  fed,  whether  by  the  nose 
or  through  the  mouth,  care  should  be  taken  to  have 
everything  ready  before  the  operation  begins.  It  is 
one  of  those  processes  which  cannot  be  done  properly  if 
it  is  only  half  prepared  for  or  attended  to  indifferently. 
The  proper  appliances  should  be  on  hand  and  within 
easy  reach.  The  food  and  medicines  that  may  become 
necessary,  if  they  have  been  previously  ordered,  should 
be  ready  for  the  doctor.  Care  should  be  taken  in 
the  preparation  of  the  food,  which  is  administered  ar- 


126  THE  NURSING  AND   CARE   OF 

dficially,  if  it  is  any  tiling  more  than  milk  or  some 
single  substance  of  a  fluid  kind.  If  gruel  or  any  form 
of  semi-solid  food,  care  should  be  taken  to  have  it  of 
the  exact  consistence,  which  is  best  administered  through 
a  tube.  When  medicines  are  ordered  to  be  given  with 
the  food,  as  for  instance  bromide  of  potassium  in  milk, 
only  just  as  much  as  is  required  should  be  mixed  at  one 
time. 

Even  when  patients  are  not  fed  by  force,  it  is  of  im- 
portance that  their  eating  should  be  carefully  watched 
and  attended  to  by  those  in  charge.  In  some  forms  of 
insanity  the  tendency  is  to  bolt  the  food  with  great 
rapidity  and  in  enormous  quantity.  So  little  control 
have  some  demented  patients  over  matters  of  this  kind 
that  they  will  choke  and  strangle  themselves,  or  fill 
themselves  to  more  than  repletion.  Such  patients 
should,  by  kind  but  firm  measures,  be  trained  to  eat 
more  slowly  and  carefully. 

It  is  sometimes  desirable  that  the  temperature  of  the 
insane  should  be  taken,  and  when  this  is  the  case  spe- 
cial precautions  should  be  used.  It  would,  for  instance, 
ordinarily,  be  foolish  to  attempt  to  take  the  temperatui'e 
of  an  insane  patient  in  the  mouth.  In  many  cases  the 
thermometer  would  either  be  broken  in  the  struggle 
which  would  take  place,  or  it  might  be  bitten  off  by  the 
patient,  and  the  glass  swallowed  with  fatal  results.  Only 
when  the  exact  mental  status  of  the  patient  is  so  well 
known  that  the  physician,  feeling  that  no  danger  can 
arise  by  taking  the  temperature  by  the  mouth,  directs 
it  to  be  done,  should  this  plan  be  followed.  The 
temperature  of  the  insane  should  therefore  usually  be 


TEE  NERVOUS  AND   THE  INSANE.  127 

taken  in  the  axilla,  and  when  taken  in  this  way  the  in- 
strument should  not  be  left  so  that  the  patient  can  take 
hold  of  it  himself.  The  nurse  should  stay  by  the  side  of 
the  patient,  and  by  preference  in  most  cases  should  hold 
the  thermometer  in  position  the  whole  time  of  the  deter- 
mination. Occasionally,  when  specially  directed  so  to 
do,  the  temperature  may  be  taken  in  the  rectum,  but 
here,  as  in  the  mouth,  great  caution  is  usually  neces- 
sary,and  it  is  often  advisable  not  to  resort  to  this  method. 

Artificial  respiration  may  have  to  be  resorted  to  at 
any  moment  in  the  care  of  suicidal  cases.  Aside  from 
self-inflicted  wounds  the  methods  most  commonly 
resorted  to  are  hanging,  drowning,  and  the  inhalation 
of  illuminating  gas. 

The  prone  pressure  method  of  artificial  respiration 
introduced  by  E.  A.  Schafer  ^  is  now  frequently  used 
instead  of  the  methods  of  Sylvester  and  Marshall  Hall. 
This  method,  in  the  distinguished  physiologist's  own 
words,  is  as  follows : 

"  The  subject,  whether  a  drowned  person  or  not,  is 
allowed  to  lie  prone,  i.e.,  face  downwards,  no  prelimi- 
nary manipulation  of  the  tongue  being  required.  The 
operator  kneels  or  squats  either  across  or  on  one  side 
of  the  subject,  facing  the  head,  and  places  his  hands 
close  together  flat  upon  the  back  of  the  subject  over  the 
loins,  the  fingers  extending  over  the  lowest  ribs.  By 
now  leaning  forwards  upon  the  hands,  keeping  the 
elbows  extended,  the  weight  of  the  operator's  body  is 

1  Schafer,  Prof.  E.  A. — "Artificial  Respiration  in  Man."  The 
Harvey  Lectures,  Delivered  under  the  Auspices  of  The  Harvey 
Society  of  New  York,  1907-8.     J.  B.  Lippincott  Company,  1909. 


128  THE  NURSING  AND   CARE  OF 

brought  to  bear  upoD  the  subject,  and  this  not  only 
compresses  the  lower  part  of  the  thorax  but  also  the 
abdomen  against  the  ground,  the  pressure  being  fairly 
equally  distributed.     The  result  of  this  is  that  not  only 
is  the  thorax  diminished  in  extent  from  before  back, 
but,  owing  to  the  pressure  which  is  communicated  to  the 
abdomen,  the  viscera  are  compressed  and  tend  to  force 
the  diaphragm  up,  so  that  the  thorax  is  diminished  in 
capacity  from  above  down.    This  is  no  doubt  the  reason 
why  the  pressure  method  when  applied  in  the  prone 
position   is   more  effective  than  when  applied,  as  by 
Howard,   in   the   supine   position.     The    pressure  is 
applied  not  violently,  but  gradually,  during  about  three 
seconds,  and  is  then  released  by  the  operator  swinging 
his  body  back,  but  without  removing  his  hands.     The 
elasticity  of  the  chest  and  abdomen  causes  these  to  re- 
sume their  original  dimensions  and  air  passes  in  through 
the  trachea.     After  two  seconds  the  process  is  again 
commenced  and  is  continued  in  the  same  way,  the  oper- 
ator swinging  his  body  forwards  and  backwards  once 
every  five  seconds  or  about  twelve  times  a  minute, 
without  any  violent  effort  and  with  the  least  possible 
exertion.     This  last  condition,  viz.,  the  absence  of  mus- 
cular exertion  other  than  that  involved  in  swinging 
forwards  and  backwards,  renders  it  possible  to  continue 
the  process  without  fatigue  for  an  indefinite  time.     It 
can  further  be  carried  out  unaided,  by  a  woman  almost 
as  well  as  by  a  man,  by  children  upon  children ;  it 
hardly  requires  to  be  taught — a  simple  demonstration 
sufficiently  teaches  it  to  a  large  audience.    Its  advantages 
in  drowning  cases  over  any  method  which  involves  the 


THE  NERVOUS  AND   THE  INSANE,  129 

supine  position  are  sufficiently  obvious — for  with  it 
there  is  no  risk  of  obstruction  by  water  or  mucus  or 
the  contents  of  the  stomach,  which  cannot  accumulate 
in  the  throat  but  must  come  away  by  the  mouth  ;  and 
the  tongue,  in  place  of  falling  back,  as  in  the  supine 
position,  falls  forwards,  and  is  unable  to  produce 
obstruction." 

The  pulmotor  has  come  into  use  recently,  and,  if  avail- 
able, should  be  employed.  It  is  easily  manipulated 
and  works  automatically. 

The  following  are  some  of  the  most  important  rules 
enforced  in  the  female  and  in  the  male  departments  of 
the  Philadelphia  Hospital  for  the  Insane : 

All  attendants,  excepting  probationers,  must  wear  complete 
uniform  while  on  duty.  Male  attendants  must  not  wear  their 
caps  in  the  wards. 

Attendants  shall  be  neat  and  tidy  in  appearance,  and  shall 
keep  their  rooms  in  neat  and  attractive  order. 

They  shall  show  kindness,  civility  and  respect  to  all  patients 
and  visitors,  and  to  each  other. 

They  shall  see  that  patients  are  properly  fed,  and  that  the 
food  is  neatly  and  properly  served. 

They  shall  not  administer  medicines  without  a  written  order 
from  the  physician.  They  shall  not  administer  food  or  medicine, 
if  refused,  except  by  the  direction  and  in  the  presence  of  a 
physician. 

They  shall  not  employ  mechanical  restraint  except  by  the 
direction  of  a  physician. 

In  every  case  in  which  force  is  necessary  to  control  violence  two 
or  more  attendants  shall  be  summoned.  Force  is  justifiable  to  pre- 
vent violence,  but  no  more  than  is  necessary  to  control  a  patient. 

Attendants  shall  not  abuse  patients  by  striking,  pulling  hair, 
laying  on  of  violent  hands,  tripping  or  pushing.  The  use  of  pro- 
fane, low  or  violent  language  is  prohibited,  also  scolding  and  loud 
calling  from  one  part  of  the  ward  to  another. 


130  THE  NURSING  AND   CARE  OF 

Attendants  shall  examine  Immediately  all  patients  as  soon  as 
they  are  admitted  to  their  respective  wards,  and  shall  note  all 
marks,  bruises  and  injuries,  and  report  them  in  writing  to  the 
Chief  Resident  Physician. 

They  shall  report  immediately  in  writing  any  accident  that 
may  occur  to  a  patient,  the  character  and  extent  of  the  injury, 
and  how  incurred.  The  escape  of  any  patient  shall  be  reported 
immediately,  and  the  manner  of  escape  stated  in  writing. 

Attendants  shall  report  immediately  to  the  physician  any 
marked  physical  or  mental  change  in  a  patient. 

They  shall  separate  any  patients  seen  to  be  quarrelling  among 
themselves. 

They  shall  not  permit  patients  to  have  matches  or  lighted 
papers,  or  to  come  in  contact  with  lighted  gas. 

They  shall  not  permit  patients  to  use  sharp  knives  or  other 
instruments  which  might  be  used  for  the  purpose  of  doing  injury 
to  themselves  or  others. 

Attendants  shall  not  leave  the  wards  or  duties  assigned  them 
without  permission  from  the  Supervisor. 

Attendants  shall  not  leave  the  Hospital  without  a  pass  fur- 
nished by  the  Chief  Resident  Physician,  and  shall  return  at  the 
date  or  time  specified  on  the  pass,  and  report  their  return  at  such 
place  as  may  be  designated  by  the  Chief  Resident  Physician. 

Attendants  shall  not  wear  part  or  parts  of  clothing  or  other 
material  belonging  to  the  Hospital,  or  use  any  material,  instru- 
ments or  apparatus  of  the  Hospital  for  their  personal  needs  with- 
out a  written  order  from  the  Chief  Resident  Physician. 

They  shall  see  that  the  wards  are  kept  clean,  and  that  there 
is  a  full  supply  of  materials  on  hand.  They  shall  report  imme- 
diately to  the  Supervisor  any  insufficiency  of  material  or  any 
damage  to  the  ward  or  its  contents. 

They  shall  be  held  responsible  for  all  articles  of  furniture, 
bedding,  ward  supplies  and  clothing  iu  their  respective  wards, 
and  if  any  article  is  missing  the  fact  must  he  reported  immedi- 
ately to  the  Supervisor. 

All  Head  Attendants  shall  keep  a  correct  laundry  list,  and  see 
that  the  full  number  of  articles  is  returned ;  that  all  goods  re- 
turned from  the  laundry  are  clean,  and  that  any  damages  are 
repaired  before  the  articles  are  used  again.    A  written  laimdry 


TEE  NERVOUS  AND    THE  INSANE.  131 

report  from  each  ward  shall  be  sent  each  week  to  the  Chief  Resi- 
dent Physician. 

No  attendant  shall  leave  the  gas  burning  in  a  room  or  ward 
that  is  not  occupied  at  the  time. 

Attendants  shall  observe  economy  in  the  use  of  all  supplies. 

They  shall  count  all  knives,  forks  and  spoons  after  each  meal 
or  service,  and  then  place  them  in  a  suitable  receptacle,  properly 
protected  from  the  patients. 

They  shall  not  allow  the  Hospital  keys  out  of  their  possession, 
and  when  a  key  is  missing  they  shall  report  the  loss  immediately 
to  the  Supervisor. 

Attendants  in  charge  of  wards  shall  see  that  all  general  clean- 
ing of  the  wards  is  stopped  while  the  physician  is  making  rounds. 
At  the  time  of  the  morning  rounds  they  shall  bring  in  line  for 
inspection  all  patients  who  are  not  in  bed  and  not  employed  out- 
side of  the  ward,  unless  excused  by  the  Chief  Resident  Physician. 

The  Head  Attendant  shall  accompany  the  physician  on  his 
rounds,  or  any  visitor  or  ofi&cer  who  may  have  occasion  to  visit 
the  ward.  All  the  attendants  shall  remain  standing  during  the 
presence  of  a  physician  or  officer  in  the  ward  or  yard. 

Attendants  shall  not  permit  visitors  to  give  the  patients  food, 
money  or  other  articles  without  permission  from  the  Chief  Resident 
Physician.  They  shall  not  permit  visitors  to  talk  to  patients  other 
than  the  patient  visited.  They  shall  not  gossip  with  visitors,  or 
give  them  any  information  concerning  the  condition  of  any  patient. 

The  attendants  shall  observe  strictly  the  rules  governing  vis- 
itors, and  see  that  these  rules  are  enforced. 

No  attendant  shall  sell  anything  to  a  patient,  or  for  any  reason 
accept  money  or  other  valuables  from  a  patient. 

Attendants  shall  not  allow  patients  to  carry  any  article  other 
than  a  handkerchief  about  their  clothing,  unless  by  special  per- 
mission from  the  Chief  Resident  Physician. 

They  shall  deliver  any  valuable  found  on  a  patient  to  the 
Chief  Resident  Physician. 

They  shall  send,  unsealed,  to  the  ofl&ce  of  the  Chief  Resident 
Physician,  all  letters,  writings  and  drawings  of  patients. 

No  attendant,  employee  or  visitor  shall  mail  any  letter  or  doc- 
ument of  a  patient  without  permission  from  the  Chief  Resident 
Physician. 


132  THE  NURSING  AND   CARE  OF 

All  attendants  shall  respond  promptly  to  fire  drill,  and  in  case 
of  fire  each  attendant  shall  be  on  duty  at  the  ward  and  place 
which  is  assigned  to  him  or  her. 

At  fire  drill,  and  in  case  of  fire,  the  Head  Attendant  shall  be 
the  last  to  leave  the  ward,  and  shall  be  sure  that  no  patient  is  left 
in  the  ward.  Attendants  shall  count  the  patients  as  soon  there- 
after as  possible. 

No  attendant  shall  have  any  communication,  verbal,  written, 
or  otherwise,  with  employees  of  the  opposite  sex,  except  such  as 
might  occur  in  fulfilling  their  respective  duties.  This  rule  shall 
apply  within  the  Institution  and  within  the  immediate  vicinity 
thereof. 

They  shall  comply  with  all  the  general  rules  and  regulations  of 
the  Institution.  They  must  bear  in  mind  that  they  are  subject 
not  only  to  these  rules,  but  to  the  state  laws  governing  the  care 
of  the  insane,  and  that  violation  of  the  rules  or  laws  may  furnish 
cause  for  reprimand,  suspension,  dismissal  or  arrest,  according 
to  the  rule  or  law  broken. 

The  head  night  attendants  shall  be  held  responsible  for  the 
condition  of  patients,  wards  and  supplies  during  the  night,  and 
report  to  the  head  day  attendants  the  condition  of  patients, 
wards  and  supplies  when  going  off  duty  at  7  a.m. 

The  head  day  attendants  shall,  in  turn,  make  a  similar  report 
to  the  head  night  attendants  when  going  off  duty  at  7  p.m. 

The  head  day  attendants  and  the  head  night  attendants  shall 
carefully  read  said  reports  and  see  that  they  are  thoroughly 
understood  before  assuming  charge. 

Any  attendant  found  sleeping  on  duty  shall  be  disciplined. 

The  night  attendants  shall  carry  out  all  instructions  relative 
to  medicine,  treatment  and  reports  as  requested  by  the  supervis- 
ing nurse.  They  shall  pay  special  attention  to  those  patients  who 
are  critically  ill  and  who  require  special  care. 

All  suicidal  and  homicidal  cases  shall  be  closely  watched  both 
during  the  day  and  night. 

The  attendants  shall  see  that  ice-picks,  drugs  and  instruments 
are  not  kept  in  the  wards,  except  in  the  infirmaries,  and  there 
they  shaU  be  kept  under  lock  and  key.  Attendants  shall  also 
see  that  the  scissors  used  for  the  general  care  of  the  patients  are 
kept  under  lock  and  key. 


THE  NERVOUS  AND    THE  INSANE.  133 

'  Night  attendants  shall  report  every  hour  to  the  night  patrol. 
They  shall  also  see  that  the  lights  are  turned  down  after  3.30 
P.M.,  and  that  there  is  no  talking  or  noise. 

Attendants  shall  not  accept  any  remuneration  or  gifts  of  any 
kind  from  the  patients  or  their  relatives. 

Attendants  shall  submit  a  correct  statement  as  to  the  number 
of  patients,  diets,  restraints  and  special  reports  to  the  ofi&ce  of  the 
supervising  nurse  not  later  than  8.30  a.m. 

No  head  attendant  shall  leave  the  ward  without  permission,  and 
then  not  until  relieved  by  a  capable  person,  who  is  to  assume  charge. 

In  case  of  death  the  attendant  shall  report  at  once  to  the  super- 
vising nurse  and  await  further  instructions. 

Attendants  shall  see  that  bodies  are  prepared  for  the  morgue 
— namely,  that  the  body  is  bathed  with  a  weak  solution  of  car- 
bolic acid,  5  per  cent. ;  the  finger  nails  and  toe  nails  trimmed 
and  cleaned  ;  the  hair  properly  prepared ;  wounds  and  ulcers 
properly  dressed  ,•  a  napkin  properly  applied  and  fastened  with 
safety  pins ;  the  body  covered  with  a  shroud,  and  a  mortuary 
sheet  folded  neatly  around  it. 

Head  attendants  shall  be  held  responsible  for  the  attendants 
and  patients  under  their  charge,  and  they  shall  also  be  held 
responsible  for  the  enforcement  of  all  rules  and  regulations 
relative  thereto. 

Attendants  shall  see  that  hot-water  bottles  and  cans  are  cov- 
ered before  they  are  applied  to  the  patients. 

Attendants,  after  arising,  shall  see  that  the  bed-covers  are 
thrown  over  the  foot  of  the  beds  and  the  windows  raised. 

ViSITOKS. 

General  visiting  will  be  allowed  on  Tuesday  and  Thursday 
afternoons,  between  1  and  4  p.m.,  and  at  no  other  time  except 
by  special  appointment  with  the  Chief  Resident  Physician. 

Visitors  who  cannot  come  week  days  will  be  admitted  Sundays 
between  9  and  11  a.m.  on  special  passes  countersigned  by  the 
Chief  Resident  Physician  and  the  Superintendent.  Such  passes 
will  be  issued  only  to  near  relatives  and  friends. 

No  patient  will  be  allowed  to  see  more  than  two  visitors  at  a 
time  or  during  a  single  week,  except  by  special  permission  from 
the  Chief  Resident  Physician. 


134  I'SE  NURSING  AND  CARE  OF 

Visitors  will  not  be  permitted  to  remain  with  a  patient  longer 
than  fifteen  (16)  minutes,  except  by  special  permission  from  the 
Chief  Kesident  Physician. 

Visitors  will  not  be  permitted  to  visit  a  patient  who  has  been 
in  the  Hospital  less  than  one  (1)  week,  unless  special  permission 
be  obtained  from  the  Chief  Resident  Physician. 

Disturbed  patients  and  patients  in  the  acute  and  infirm  wards 
shall  not  be  visited  of  tener  than  once  each  week,  or  as  the  Chief 
Resident  Physician  may  designate. 

Patients  critically  ill  may  be  visited  as  frequently  and  for  as 
long  a  time  as  the  Chief  Resident  Physician  or  Assistant  Physi- 
cian may  direct. 

Visitors  shall  not  give  personally  any  food,  candy,  ice  cream, 
tobacco,  matches,  paper,  medicine,  or  articles  of  any  kind  directly 
or  indirectly  to  a  patient. 

Visitors  shall  not  bring  or  send  to  patients  any  food  or  article 
(other  than  fruit,  flowers)  or  select  reading  matter  (other  than  re- 
ligious reading) ;  and  all  packages  must  be  left  in  the  office  of  the 
Chief  Resident  Physician,  with  the  patient's  name  on  the  package. 

Visitors  shall  not  converse  with  attendants.  All  information 
concerning  patients  must  be  obtained  from  the  Chief  Resident 
Physician  or  Assistant  Physicians. 

Visitors  shall  not  secure  the  signature  of  a  patient  to  any  doc- 
ument or  paper  except  by  the  permission  and  in  the  presence  of 
the  Chief  Resident  Physician. 

Visitors  shall  not  speak  to  any  patient  other  than  the  patient 
visited. 

Visitors  shall  not  mail  letters  to  patients,  or  take  away  from 
the  department  any  message  written  by  patients.  All  written 
communications  to  patients  shall  pass  through  the  oflice  of  the 
Chief  Resident  Physician. 

Complaint  regarding  any  neglect,  incivility  or  inattention  on 
the  part  of  employees  shall  be  made  to  the  Chief  Resident  Phy- 
sician as  soon  as  possible. 

No  loud  talking,  scolding,  violence,  or  intoxication  on  the  part 
of  visitors  will  be  permitted. 

Visitors  may  see  the  Chief  Resident  Physician  or  Assistant 
Physicians  at  the  prescribed  visiting  hours. 

"  The  members  of  families  of  patients,  their  personal  friends, 
agents,  or  attorneys,  shall  be  permitted  to  visit  them  not  less 


THE  NERVOUS  AND   THE  INSANE.  135 

than  once  in  two  weeks,  unless  the  medical  ofl&cer  consider  the 
visit  likely  to  be  injurious  to  such  patient,  or  otherwise  inexpe- 
dient, in  which  case  he  shall  so  state  in  writing,  if  requested, 
giving  his  reasons  therefor,  and  a  copy  of  such  writing  shall  be 
given  to  every  visitor,  if  requested,  who  is  refused  a  personal 
interview  with  the  patient." — Rules  and  Regulations  of  the 
Committee  on  Lunacy  of  the  Board  of  Public  Charities,  State  of 
Pennsylvania. 

I  will  conclude  this  chapter  by  quoting  in  full  the 
quaint  description  of  the  "  Good  Attendant/'  by  Dr. 
Eayi: 

"  The  good  attendant  never  shirketh  his  appointed 
work,  and  it  is  not  in  him  to  be  satisfied  with  just  that 
measure  of  performance  which  will  enable  him  to  keep 
his  place.  He  elevateth  his  employment  by  the  manner 
in  which  he  performeth  its  duties.  Though  offensive 
to  the  senses,  or  trying  to  the  temper,  or  exhaustive  of 
patience,  as  many  of  them  are,  yet  he  meeteth  them  all 
faithfully  and  promptly.  Like  every  true  man  and  true 
woman,  he  findeth  that  dignity  inherent  in  every  good 
work,  that  ennobles  even  the  meanest  service.  As  the 
good  artisan  rejoiceth  over  some  choice  specimen  of  his 
craft,  wrought  by  his  own  hand,  so  doth  the  good  at- 
tendant rejoice  when,  after  much  toil  and  trial,  he  seeth 
the  mind  of  his  patient  coming  out  from  under  the 
cloud.  To  hasten  this  blessed  consummation,  he  spareth 
neither  time  nor  trouble,  rendering  every  attention 
needful  for  the  bodily  comfort,  and  by  unceasing  arts 
of  kindness  soothing  the  troubled  spirit.    The  good  at- 

1  "  Ideal  Characters  of  the  Officers  of  a  Hospital  for  the  In- 
sane."    By  I.  Ray,  M.D. 


136  THE  NURSING  AND   CARE  OF 

tendant  is  ever  gentle  in  his  words  and  ways,  and  under 
no  provocation  will  he  return  a  blow  or  an  abusive 
word.  Unlike  the  people  of  former  times,  who  be- 
lieved that  the  insane  must  first  be  made  to  feel  that 
they  have  a  master  in  their  keeper,  and  for  this  purpose 
resorted  to  threats  and  blows,  he  seeketh  to  obtain  the 
desirable  control  by  gaining  the  patient's  respect,  and 
this  he  well  knoweth  will  not  follow  angry  words,  or 
harsh  measures,  or  any  form  of  intimidation. 

"  The  good  attendant  never  attempteth  to  reason  his 
patient  out  of  his  false  beliefs,  and,  as  far  as  practica- 
ble, he  preventeth   him  from  conversing  about  them. 
He  knoweth  that   argument   giveth   them   additional 
strength,  besides  exciting  and  souring  the  temper.     He 
refraineth  from  joking  on  the  notions  or  circumstances 
of  his  patient,  for  he  hath  learned  that  the  disordered 
mind  is  impervious  to  a  joke,  but  rather  construes  one 
into  an  insult.     He  is  careful  to  obey  every  change, 
bodily  or  mental,  for  better  or  worse,  and  maketh  due 
report  thereof  to  the  physicians.     His  constant  pres- 
ence with  the  patients  giveth  him  opportunity  to  see 
and  hear  much  that  may  escape  the  attention  of  the 
officers  in  their  casual  visits,  and  his  eyes  and  ears  are 
ever  open  for   this  purpose.     Especially  doth  he  en- 
deavor to  inspire   his  charge  with  confidence  in  the 
physicians,  always  holding  them  up  as  his  friends  and 
protectors,  who  will  never  see  him  wronged  or  injured. 
When  abroad,  he  refraineth  from  entertaining  company 
with  the  fancies  or  conduct  of  his  patients,  nor  is  he 
swift  to  pour  into  itching  ears  the  gossip  of  the  house. 
The  rules  made  for  the  government  of  attendants  he 


THE  NERVOUS  AND    THE  INSANE.  I37 

faithfully  follows,  bound  thereto  hj  a  sense  of  respect 
for  himself  and  of  fair  dealing  with  his  employers. 

"The  good  attendant  avoideth  all  vulgar  ways  in 
language,  dress,  or  demeanor,  as  well  as  all  familiarities 
which  he  would  never  venture  upon  outside  of  the 
hospital.  He  beareth  in  mind  that  the  people  who 
have  fallen  to  his  charge,  however  perverted  or  de- 
graded by  disease,  were  once  as  good  as  himself,  if  not 
better,  and  have  done  nothing  to  forfeit  their  claims  to 
his  respect  and  protection.  For  deficiencies  of  culture 
and  of  good  breeding,  he  more  than  maketh  up  by 
gentle  words,  acts  of  kindness,  and  little  attentions. 
Especially  is  the  female  attendant  not  to  add  fresh 
poignancy  to  the  sorrows  of  her  charge  by  coarse  ex- 
pressions, untidy  ways,  and  manners  utterly  devoid  of 
refinement." 


INDEX. 


Air  cushions,  41. 

Alternate    Lot    and    cold    applica- 
tions, 67. 
Amusement  of  the  insane,  113. 
Anderson  on  tact  in  nurses,  13. 
Apoplexy,    Bowles's    recommenda- 
tion as  to  position  in,  32. 
general  management  of,  83. 
hemorrhagic,  32. 
position  in,  33. 
signs  and  symptoms  of,  32. 
what  to  do  in  case  of,  35. 
Applications  of   heat  and   cold   to 

the  insane,  113. 
Artificial  respiration,  127. 
Attendants,  scientific  interest  of,  in 
the  patients,  101. 
tests  of  good,  109. 
the  best,  104. 

Bath,  continuous,  66. 

intermittent,  67. 
Bathing,  65. 

dangers  of,  among  the  insane, 
116. 

of  the  insane,  116. 

rules  for,  116. 
Beard   and    Rockwell's   method  of 

general  faradization,  94 
Bed-sores,  40. 

acute,  41. 

plans  of  treatment  for,  41. 

prevention  of,  42. 

treatment  with  galvanic  plates, 
42. 
Bladder,  washing  out  of,  40. 
Breathing,  stertorous,  32. 

Cases,  different  classes  of  nervous 
and  insane,  11. 
of  chronic  organic  nervous  dis- 
ease, 38. 


Cerebral    hemorrhage,    acute    bed- 
sores in,  41. 

Cheyne-Stokes  breathing,  34. 

Cleanliness  of  nurses  of  attendants 
upon  the  insane,  116. 

Cleansing  of  feeding-tube,  124. 

Conducting  cords,  86. 

Conjugate  deviation  of  the  eyes  and 
head,  34. 

Consciousness,  loss  of,  in  epilepsy 
and  in  hystero-epilepsy,  23. 

Constipation  among  the  insane,  115. 

Continuous  bath,  66. 

Cotton,  use  of  absorbent,  86. 

Current-carrier,  84. 

regulators  or  modifiers,  78. 

Defects  in  nurses  and  attendants, 

110. 
Delirium,  treatment  of,  43. 
Delirium  tremens,  43. 
Delusions,  101. 

suppression  of,  by  patients,  101. 

which  lead  to  mutilation,  102. 
Diet,  purin-free,  27. 
Drunkenness,  diagnosis  of,  36. 

management  of,  33. 

signs  and  symptoms  of,  36. 
Dubois-Reymond  coil,  74. 

Eating,  watchfulness  of,  among  the 

insane,  126. 
Educational  training  of  the  insane, 

113. 
Electrical  apparatus,  importance  of 
keeping  clean,  82. 
applications,  deep-seated,  88. 
direct  and  indirect  methods 

of,  88. 
to  the  face,  91. 
to  the  joints,  92. 
to  the  skin,  92. 
to  timid  patients,  80. 
139 


140 


INDEX. 


Electricity  after  meals,  90. 

forms  of,  used  in  medicine,  72. 
how  far  it  should    be  used  by 

nurses,  70. 
methods  of  applying,  90. 
position  of    limbs  and  muscles 

in  using,  90. 
what  a  nurse  should  know  about, 
71. 
Electrodes,  84. 

for   application   beneath  a  pa- 
tient's clothing,  84. 
how  to  hold,  87. 
method  of  covering,  86. 
methods  of  cleaning,  85. 
Epilepsy,  general  care  of  patients 

suffering  from,  25. 
Epileptic  seizure,  aura  preceding,  26. 
description  of,  24. 
management  of,  25. 
Epileptics,  amount  and  character  of 
food  for,  27. 
peculiar  abnormal  mental  states 

of,  27. 
rules  for  management  of,  28. 
Eschars,  acute,  41. 
Estraderd  on  the  varieties  of  mas- 
sage, 49. 
Exercise  for  the  insane,  115. 
Exhaustion,  heat,  35. 
Exhaustion  produced  by  electrical 

applications,  90. 
Expedients  for  amusing  and  occupy- 
ing patients,  14. 

Fainting,  38. 

Faradic  apparatus  for  office  table, 
77. 
battery,  description  of,  72. 
harm  done  with,  82. 
hints    about    handling    and 
caring  for,  81. 
current,  how  to  start  a,  75. 
machine,  other  names  for,  72. 
Faradism,  when  to  use,  91. 
Faradization,  general,  93,  94. 
Favoritism  of    nurses    and  attend- 
ants, 108. 


Fibrositis,  59. 

Food,  directions  as  to  its  prepara- 
tion, 44. 
insufficient  or  too  much,  among 

the  insane,  110. 
preparation  of,  for  forcible  feed- 
ing, 126. 
Forcible  feeding  of  the  insane,  117. 
three  methods  of,  119. 

Galvanic  current,  83. 
Grease   or    liniments    in    massage, 
54. 

Hsematoma-auris,  100. 

Hallucinations,  101. 

Hamilton,  Allen    McLane,   on   the 

use  of  revulsives,  68. 
Heat  prostration,  36. 
Helplessness,  how  to  be   useful  in 

cases  of,  39. 
Hydrotherapy,  65. 
Hysteria,  21. 

among  the  insane,  103. 
Hysterical  attacks,  involuntary,  23. 
simulated,  23. 
cases,  general    management  of, 

22. 
seizures,  different  forms  of,  22. 
Hystero-epilepsy,  23. 

with  separate  crises,  24. 

Illusions,  101. 

Insane,    attention    to    little    things 
among  the,  109. 
ear,  100. 

hysteria  among  the,  103. 
nursing  and  care  of,  in  private 

practice,  106. 
patients,  methods  of  seizing  or 

holding,  112. 
ridicule  of  the,  108. 
Insanity,  practical  hints  as  to  dif- 
ferent forms  of,  98. 
simulation  of,  by  the  sane,  103. 
of  sanity  by  the  insane,  103. 
what    a    nurse     should     know 
about,  98. 


INDEX. 


141 


Insfensibility,  cause  and  nature  of, 

in  various  affections,  31. 
Intermittent  bath,  67. 
Involuntary  evacuations  among  the 

insane,  115. 
Jacoby  on  the  methods  of  massage, 
50,  51,  52,  53. 

Kneading,  52. 

Lee,  Dr.  Benjamin,  on  derivation  of 

word  massage,  48. 
Levenstein's  treatment  of  narcotic 

habit,  45. 
Loyalty  of  nurse  to  the  doctor,  15. 

Manuals  for  attendants  on  the  in- 
sane, 96,  97. 
Massage  k  friction,  51. 
chapter  on,  46. 

complaint  of  patients  as  to,  48. 
definitions  of,  49. 
derivation  of  word,  48. 
direction  of,  55. 
grease  or  liniment  in,  54. 
immediate,  49. 
mediate,  49. 
number  of  patients  to  be  treated 

in  one  day,  56. 
position  of    muscles  and  limbs 

in,  53. 
rough  handling  of  patients  in, 

57. 
so-called  methods  of,  49. 
special  instruction  in,  46. 
temperature  and  ventilation  of 

room  in,  58. 
terms  to  describe  the  process  of, 

49. 
the  four  essential  methods  of,  50. 
the  use  of  both  hands  in,  54. 
twisting  or  wringing  movements 

in,  55. 
wrist  movements  in,  54. 
Masseur,  53. 

Masseurs,  mental  requirements  of, 
58. 
knowledge    of    anatomy    and 
.  jihysiology  by,  47. 


Masseuse,  53. 

Meningitis,  43. 

Mitchell,  S.  Weir,  on  a  nurse  for 

cases  under  rest  treatment,  14. 
Mitchell,  S.  Weir,  remarks  on  nurses 

for  nervous  patients,  12. 
Motor  points,  89. 
Movements,  60. 

active,  passive,  single,  and  du- 
plicated, 61. 
description  of  duplicated  active 

61. 
design  of  duplicated  active,  62. 
Moxey'a  method  of  forcible  feeding, 

119. 
Murrell  on  massage,  48. 
Muscles,  arrangement  of,  47. 
Muscular    applications,    hints    and 

cautions  about,  88. 
Mutilation,  delusions  of,  102. 

Narcotic  habit,  44. 
Nasal  feeding,  difficulties  and  dan- 
gers of,  121. 
Nurse,  decided,  13. 
domineering,  13. 
from  a  good  family,  17. 
qualities    and  qualifications  of, 

for  nervous  patients,  11. 
the  conceited  and  the  too  hum- 
ble, 17. 
the  too  familiar,  16. 
the  vain,  17. 

who  does  not  talk  enough,  16. 
who  is  nursing  because  she  loves 

the  business,  18. 
who  makes  the  diagnosis,  16. 
who  quarrels  with  the  servants, 

18. 
who  talks  too  much,  16. 
who  will  nurse  only  one  type  of 
cases,  19. 
Nurses,  types  of  faulty,  16. 

and  attendants,  defects  in,  105. 

Observation,  habits  of,  13. 
Occupation  of  the  insane,  113. 
Opium  habit,  44. 


142 


INDEX. 


Opium,  management  of   narcotism 

by.  33. 
Overwork  by  the  insane,  114. 

Pack,  cold,  66. 

hot,  66. 
Paralysis  of  the  bowels  or  bladder,  39 . 
Paralytic  cases,  38. 
Patient's  view  of  nurses,  19. 
Percussion,  50. 
Petrissage,  60. 
Physical  condition  of  masseurs  and 

masseuses,  56. 
Playfair  on  nurse  for  cases   under 

rest  treatment,  15. 
Pole.  83. 
PrJmotor,  129. 

Ray's  description  of  the  "Good  At- 
tendant," 135. 

Recording  treatment  of  insane  pa- 
tients, 109. 

Respiration,  artificial,  127. 

Restraint,  mechanical,  in  the  care  of 
the  insane,  112. 

Rheotome  or  current-interrupter  of 
f  aradic  machine,  78. 

Rub,  salt,  66. 

Rubbing.  51. 

Rules  in  force  for  insane  hospitals, 
129. 

Salt  rub,  66. 

Simulation  of  insanity,  103. 

Sleeplessness,  42. 

Social  service,  21. 

Southey's,  Dr.  Reginald,  recommen- 
dation in  supposed  drunkenness, 
37. 


Spencer  Well's   treatment  of   bed- 
sores and  ulcers,  42. 
Spitzka's  description  of  forcible  feed- 
ing, 123. 
Sponge  bath,  65. 
Static  electricity,  72. 
Stertor  in  apoplexy.  32. 
Bowles's  views  on,  32. 
relief  of,  by  position,  33. 
Stomach-tube,  125. 
Stroking,  50. 

Suicide,  methods  of,  among  the  in- 
sane, 110. 
protection  of  the  insane  from, 
110. 
Sunstroke,  35. 

Tact,  13. 

Tapotement.  52. 

Temperature,  methods  of  lowering, 

36. 
methods  of    taking    among  the 

insane,  126. 
Tetanus,  43. 
Thermic  fever,  35. 

Ursemic  coma,  37. 

measures  and  remedies  for  treat- 
ing, 37. 
signs  and  symptoms  of,  37. 

Water-bed,  41. 
Water-cushions,  41. 
Water-rheostat,  80. 
Wet  pack,  66. 
Work  for  the  insane,  114. 


THE   END. 


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